clinical case SYNCHRONOUS RENAL AND RIGHT COLON CANCER: A RARE ASSOCIATIONDr. Juliano Cesar Moro - Division of Urology, FCM - UNICAMP
CLINICAL BACKGROUND Forty seven year-old male patient works with cropping and participates in a bariatric surgery program. He undergoes an abdominal US as pre-operative workup which shows an expansive solid lesion in the left kidney. He denies hematuria, pain or any other symptoms. Patient was referred to Urology.
Comorbidities: morbid obesity, arterial hypertension and Type 2 Diabetes Mellitus. No previous surgery. Physical exam: BMI: 41. Non tender abdomen. Normal labs except for fasting glycemia 130 mg/dL
Ultrasound
Expnasive lesion with mixed solid-cystic aspect in the upper pole of left kidney. Abdminal CT scan: Left kidney lesion (Fig.1) involving upper pole, measures 11,6x9,7x9cm, heterogenous dye perfusion, likely a renal primary tumor. No lymphadenopathy. Left renal vein with no sign of thrombi.
DIAGNOSTIC WORKUP: Left renal tumor Patient underwent radical left nephrectomy, post operative outcome was uneventful. Pathology: Clear cell renal carcinoma, Fuhrman 1/2, solid tubular architecture, areas of necrosis. Hylum vessels with no signs of neoplasia. Perirrenal fat with no signs of neoplasia At one year of follow up, CT scan showed; -Well defined expansive lesion (Fig. 2), with irregular borders occupying left renal topography with 6x5x4cm, heterogenic perfusion after IV dye; close contact with spleen and pancreatic cauda -Thickening of transverse colon wall in about 4 cm proximally to the hepatic angle.
Colonoscoy was proposed: -Vegetating ulcerative lesion in transverse colon that avoids endoscopic progression. Biopsies were undertaken.
Pathology: moderately differentiated adenocarcinoma in tranverse colon Diagnosis: Left renal cancer recurrence? Synchronous colon tumor? MANAGEMENT
Total colectomy was the treatment of choice. Total colectomy (Fig. 3) + Left renal topography recurrence lesion ressection + lymphadenectomy. Removal of lesion in the topography of left renal kidney demanded in bloc ressection of spleen and pancreas tail (Fig. 4).
. Pathology : Transverse colon adenocarcinoma moderate/ poorly differentiated measuring 7,0x4,0x0,9cminfiltrating pericolic tissue (pT3)
Metastasis to 3 of 105 lymphnodes (pN1b). Margens Pathology stage: pT3, pN1b. Stage: III B Left renal topography lesion: Clear cell carcinoma from the adrenal gland measuring 10,5x5,0x4,5cm.
COMMENT - Dr. Carlos AR Martinez - Division of Proctology, FCM - UNICAMP
Simultaneous occurrence of renal and colon cancers is a rare event. Most data in medical Literature consists of case reports. The pathogenesis involved in the etiology of this rare event is still obscure. A recent study reported on a higher risk of developing colon cancer in patients suffering from sporadic urological tumors affecting ureter and renal pelvis and vice versa. This bidirectional association is believed to be associated with subject exposition to the same range of risk factors (smoking, diet, etc). However, after a better understanding of molecular biology and pathology of these tumors it became clearer that association between uro-epithelial and renal neoplasias and colorectal cancer may derive from known genetic mutations. Currently, there are approximately 10 different well defined genetic syndromes that are related to enhanced risk of developing several types of renal cancer. Genetic alterations related to renal uro-epithelial tumors and hereditary non polipose colorectal cancer (HNPCC) or Lynch syndrome are long known. In the later, genes related to DNA repair system (hMLH1, hMSH2, hMLh6) are functionally damaged. As a consequence those who harbor mutation in one of these genes have a risk of 80% of developing colon, endometrium, ovary, ureteral or renal cancer. However, it is worth mentioning that Lynch Syndrome related kidney tumors are uro-epithelial; which differs from the presented case where the patient presented with a clear cell renal carcinoma. It has been recently demonstrated that somatic inactivation of tumor suppressor gene that is related to Von Hippel-Lindau (VHL) and is located at the chromosome 3 (3p25-26) is key for the development of clear cell carcinoma and colorectal cancer, as in the case report. Somatic inactivation of tumor suppressor genes in VHL disease is considered an early event and has been described in more than 60% of clear cell carcinoma cases. Another example of association between genetic alterations and primary synchronic kidney and colon cancers is Birt-HoggDubĂŠ disease. There is a mutation in gene FLCN which is located at the short arm of chromosome 17 (17p11.2) and codifies a tumor suppressing protein (foliculin). In face of these recent evidence and better understanding of the genetic mechanisms involved in human carcinogenesis, the association of primary tumor at different sites should not be regarded as a coincidence, but may demand genetic investigation and familiar genetic counseling.
Suggested Literature:
1. Aarnio M, Säily M, Juhola M, Gylling A, Peltomäki P, Järvinen HJ, Mecklin JP. Uroepithelial and kidney carcinoma in Lynch syndrome. Fam Cancer. 2012;11(3):395-401. 2. Zinnamosca L, Laudisi A, Petramala L, Marinelli C, Roselli M, Vitolo D, Montesani C, Letizia C. Von Hippel-Lindau disease with colon adenocarcinoma, renal cell carcinoma ans adrenal pheocromocitoma. Inter Med. 2013;52(14):1599-603. 3. Kashiwada T, Shimizu H, Tamura K, Seyama K, Horie Y, Mizoo A. BirtHogg-Dubé syndrome and familial polyposis: na association or a coincidence? Intern Med. 2012;51(13):1789-92. 4. Palmirotta R, Savonarola A, Ludovici G, Donati P, Cavaliere F, DE Marchis ML, Ferroni P, Guadagni F. Association between Birt-Hogg-Dubé syndrome and cancer predisposition. Anticancer Res. 2010;30(3):751-7. 5. Haas NB, Nathanson KL. Hereditary kidney syndromes. Adv Chronic Kidney Dis. 2014;21(1):81-90.
COMMENT - Dr. Daniel Lahan Martins - Division of Radiology, FCM - Unicamp
In this case, initial diagnosis of renal tumor was obvious as it is a large lesion and tomographic characteristics (vascularity, heterogeneity and necrosis areas) suggested conventional clear cell carcinoma as the main diagnostic hypothesis. At 1 year follow up after nephrectomy imaging showed a solid heterogenous lesion filling the left renal site empty space that suggested local recurrence. Parietal wall thickening of transverse colon was also noted with tumoral charactersistics which demanded further investigation. Recurrence of clear cell renal carcinoma after therapeutic surgical approach can reach 20-50% of cases may they be local or distant (metastasis). Additional treatment is required. Local recurrence is more likely to occur if primary tumor is large, has a high histological grade or has an advanced T stage. Although protocols to follow these patients up are varied, CT scan or MRI are mandatory in detecting recurrence. Magnetic resonance imaging (MRI) has a similar sensitivity to CT and is rather used in young patients who may demand sequential imaging for a long time of oncologic follow up and in those allergic to iodine contrast. For the remaining of patients CT scan can be used. Both CT and MRI present local recurrence as a contrast enhancing solid mass at the topography of the removed organ. Lesion may involve quadratum lumbar muscle and psoas muscle, dislodging or invading retroperitoneal structures. It may also invade adrenal gland if this is spared during surgery. Colon cancer simultaneous occurrence was an interesting finding in the present case. Although Lynch Syndrome evidences clearly the association between colorectal and urothelial cancers the association between colorectal cancer and clear cell kidney cancer is not as usual. Nonetheless these patients seem to present a higher risk for other malignant tumors and therefore must be kept under careful surveillance.
Suggested Literature:
- American College of Radiology (ACR) Appropriateness Criteria. Posttreatment Follow-up of Renal Cell Carcinoma. 1996, last update: 2013 (http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/Post TreatmentFollowUpRenalCellCarcinoma.pdf). - Itano NB, Blute ML, Spotts B, Zincke H. Outcome of isolated renal cell carcinoma fossa recurrence after nephrectomy. J Urol. 2000;164(2):322-325. - Steinhagen E, Moore HG, Lee-Kong SA, Shia J, Eaton A, Markowitz AJ, Guillem RP. Patients With Colorectal and Renal Cell Carcinoma Diagnoses Appear to Be at Risk for Additional Malignancies. Clinical Colorectal Cancer 2013;12:23-27.
learning by image RENAL TRANPLANTATION WHITH HORSESHOE KIDNEY Edilson Fernando da Cruz dos Santos Silva, MD; Marcelo Lopes Lima, MD, PhD.
CLINICAL MANAGEMENT Anatomical variation with a horseshoe kidney was found during deceased donor kidney harvesting (Figure 1). Organ was prepared in backtable dissection and properly perfused with Collins solution; a decision was made towards splitting the horseshoe kidney in half at the isthmus region in order to provide two separate implants. (Figure 2). One only renal artery and one vein were isolated and one ureter as well bilaterally ureter (Figure 3).
Implant of left half kidney was performed in right iliac fossae and arterial anastomose was terminal between internal iliac artery and renal artery; while venous anastomose was terminolateral between external iliac vein and renal vein. Ureter was reimplanted using modified Gregoir technique (Figure 4). Right half of horseshoe kidney was implanted in a distinct receptor in left iliac fossae using the above described technique.
Cold ischemia time was estimated to be 16 hours for the first implant and 20 hours for the second one. Both patients had adequate blood perfusion on Doppler ultrasound at postoperative day one.
Patients 1 and 2 were discharged at postoperative days 9 and 13 with diuresis of 2700 ml and creatinine of 1.2 mg/dl and 2400 ml and 1.7 mg/dl, respectively.
RECEPTORS ASPECTS
Fifty-three years old male patient is under dialysis for 2 years for chronic renal failure secondary to systemic hypertension. Patient presents a residual voiding volume of 1000 ml.
The other receptor is a fifty-nine years old male patient with renal failure secondary to both diabetes and systemic hypertension under dialysis for 5 years, no residual voiding volume.
Figure 1: Deceased donor horseshoe kidney. Red arrow points out the aorta artery before it bifurcates into renal arteries. Black arrow identifies renal vein towards the left half of horseshoe kidney. White arrows point out the ureters.
Figure 2: Medial cut in horseshoe kidney. Black arrow identifies the exact point of renal cut preserving renal parenchyma and hylum structures to both portions.
Figure 3: Left portion kidney. Black arrow identifies left renal artery, red arrow points out left renal vein and white arrow signs the left ureter.
Figure 4: Left half implanted in right iliac fossa (Black arrow). White arrow points out dilated pelvis.
COMMENTARY William C. Nahas, MD., PhD. Professor of Urology Hospital das ClĂnicas da FMUS
Horseshoe kidney is a relatively common abnormality of renal fusion, with incidence ranging from 1 to 600-800 adults. This anatomical variation is usually accompanied by vascular and ureteral variations, and the usual presence of multiple arteries and veins from the aorta / cava and iliac vessels . The horseshoe kidney vascularization is present as a complex form so that in one third of cases the renal artery is unique for each side. The ureteropelvic junction obstruction can occur in up to 35 % of patients. However, the shortage of organs to meet the growing demands of patients in queue renal transplantation has become the use of horseshoe kidney an interesting option.
Most publications describing the technique of transplantation of horseshoe kidney are case reports or small case series ( 1 , 2 ) . This can be transplanted en bloc or after division at the isthmus, as well illustrated by the case presented. This decision should be based on the morphology of the renal isthmus, position and number of renal vessels and anatomy of the collecting system. By 2008, 34 horseshoe kidneys were transplanted into 50 recipients, and 15 received kidneys en bloc and 35 after division (3 renal units were discarded by the complexity of vascularization). In a follow-up of six months, 82% of grafts showed good function. Twenty-one recipients had follow-up greater than or equal to 1 year, with all good developments. Despite the complexity of vascular, only 1 case developed graft thrombosis ( 3 ) .
It is currently believed that the results of transplantation to the horseshoe kidney are similar to the normal kidney transplantation (4). Therefore, this practice should be encouraged and widespread so as to increase the number of kidneys available for transplantation and to decrease the line.
References:
1. Nelson RP, Palmer JM. Use of horseshoe kidney in renal transplantation: technical aspects. Urology. 1975;6(3):357-9. 2. Nahas WC, Hakim NS, Mazzucchi E, Antonopoulos LM, Eltayar AR, Labruzzo C, et al. Transplantation of horseshoe kidney en bloc. International surgery. 2000;85(3):272-4. 3. Pontinen T, Khanmoradi K, Kumar A, Kudsi H, Cheng Kung S, Chewaproug D, et al. Horseshoe kidneys: an underutilized resource in kidney transplant. Experimental and clinical transplantation. 2010;8(1):74-8. 4. Stroosma OB, Schurink H, Kootstra G. Current opinions in horseshoe kidney transplantation. Transplant international. 2002;15(4):196-9.
new technologies ENDOSCOPIC GOLD FIDUCIAL MARKER PLACEMENT INTO THE BLADDER WALL TO OPTIMIZE RADIOTHERAPY TARGETING FOR BLADDER-PRESERVING MANAGEMENT OF MUSCLE-INVASIVE BLADDER CANCER: FEASIBILITY AND INITIAL OUTCOMES Maurice M. Garcia1, Alexander R. Gottschalk, Jonathan Brajtbord, Badrinath R. Konety, Maxwell V. Meng, Mack Roach, III, Peter R. Carroll PLOS ONE |March 2014 | Volume 9 | Issue 3 | e89754
ABSTRACT Radical cystectomy is the standard treatment of muscle invasive bladder cancer. However, in patients whose surgical risk is discouraging, the trimodal therapy (TUR, chemotherapy and radiation therapy ) is the alternative . Ideally, cases should be low stage disease and likely focal complete transurethral resection . There are no randomized studies comparing cystectomy versus trimodal therapy. There are two main challenges for radiotherapy treatment with bladder preservation: the continuous movement of the bladder and no identification of the resected tumor bed through TC . In an attempt to improve the target radio, was formulated hypothesis deploy markers around the tumor site in order to guide therapy. This study aims to describe the marker adopted, the implantation technique, its safety and initial experience with the first 18 patients ( pT2NxM0 ) . The marker used was a device of 24K gold that has a 2.1 mm micro - barbs (photo) . Gold was chosen due to its high density metal and therefore excellent visualization through imaging methods. The devices were implanted in the bladder 1 cm from the edge of the RTU with needle cystoscope (adapted) submucosa. Altogether 3 to 5 markers were placed together with a portion of Gelfoam to prevent migration. The implantation of the devices was performed under standard bladder filling 60 mL of contrast solution for simultaneous fluoroscopy. No complications associated with markers and found a rate of 98 % retention of implant devices in bed until the end of radiotherapy were described.
Studies are underway to evaluate the irradiated patients guided by gold markers. One should check for reduction of dosimetry, decreased radiation field sparing neighboring organs and oncological results.
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urology news PHD THESIS AT DIVISION OF UROLOGY, UNICAMP February 26, Ms. Adélia Lucio presents the following research: COMPARISON OF TRANSCUTANEOUS TIBIAL NERVE STIMULATION AND INTRAVAGINAL NEUROMUSCULAR ELECTRICAL STIMULATION IN THE TREATMENT OF LOWER URINARY TRACT SYMPTOMS IN WOMEN WITH MULTIPLE SCLEROSIS
Faculty members of the examining board: Antonio Gugliotta (Suplent), Jose Tadeu Tamanini, Maria Helena Baena Lopes, Adelia Lucia (Candidate), Carlos D’Ancona (Mentor), Patricia Driusso, Simone Botelho Pereira, Maria Carolina Perisinnotto (Suplent).
ABSTRACT
Objectives: The aim of this study is to compare two methods of electrotherapy, most used in clinical practice for the treatment of lower urinary tract symptoms (LUTS), the transcutaneous tibial nerve electrostimulation and intravaginal electrostimulation in women with multiple sclerosis (MS) and its influence on sexual function and Quality of Life (QOL) of these women. Methods: A prospective, randomized, blinded clinical trial was carried out. Thirty women with MS and LUTS were randomly allocated into one of three groups and received treatment for 12 weeks: Group I: pelvic floor muscle training (PFMT) with electromyographic (EMG) biofeedback and sham electrostimulation (GI, n=10), Group II: PFMT with EMG biofeedback and intravaginal electrostimulation (GII, n=10), Group III: PFMT with EMG biofeedback and transcutaneous tibial nerve stimulation (GIII, n=10). Assessments, performed before and after the treatment, included: 24 hours pad test, three days bladder diary, PFM functioning according to the PERFECT scheme, tone and ability to relax PFM, flexibility of vaginal opening and maximum cystometric capacity, bladder compliance, maximum amplitude of detrusor overactivity, maximum flow rate (Qmax), detrusor pressure at Qmax and post-void residual volume outcomes of urodynamic study. The questionnaires included: OAB-V8, ICIQ-SF, Qualiveen and, the questionnaire of sexuality, FSFI. Results: After treatment, all groups showed a reduction in pad weight and reduced episodes of urgency and urge incontinence. They also showed improvements in all domains of the PERFECT scheme, decreased scores of OAB-V8 and ICIQ-SF questionnaires and increased scores of arousal, vaginal lubrication, satisfaction and total score domains of FSFI questionnaire. GII was significantly improved when compared to GI and GIII related to tone, flexibility and relaxation of PFM and, also, in the score of OAB-V8 questionnaire. Conclusion: The results suggest that PFMT alone or in combination with intravaginal electrostimulation or transcutaneous tibial nerve electrostimulation is effective in the treatment of LUTS and sexual function in MS patients, with the combination of PFMT and intravaginal electrostimulation offering some advantage in the reduction of muscle tone and LUTS. Keywords: Pelvic floor muscle training, Electrostimulation, Lower Urinary Tract Symptoms, Multiple Sclerosis.
WHY JOIN THE INTERNATIONAL CONTINENCE SOCIETY (ICS) The study of voiding dysfunction and urinary incontinence reached such complexity that can no longer be restricted to a particular medical specialty. For this reason it was created the International Continence Society, a nonprofit organization that brings various medical and non-medical specialties with the aim of improving the diagnosis and treatment of various voiding dysfunctions as well as related research. For its coverage ICS became the Society that allows Urologists, Gynecologists and other experts to make contact with the latest advances in the diagnosis and treatment of voiding disorders they are performed by doctors, physical therapists, nurses etc and all who promote improving the quality of life based on the improvement of voiding conditions of the patients. The ICS offers its members wide variety of educational materials as well as courses and multidisciplinary symposia values associated to low enrollment, allowing its members enhance their knowledge and promote urinary continence in different regions of the planet. In addition the Company has representation in several parts of the world contributing to the exchange and sharing of experiences between professionals from different continents. Since your character is a pluralistic society that widely gets all members who wish to take up positions and work Enjoy, be ICS members and earn 25% discount on registration for the Congress in Rio de Janeiro. For all these reasons we believe this to be the correct affiliations for all medical and non-medical professionals interested in promoting urinary continence as a tool for improving the quality of life entity.
Nucelio Lemos Scinetific Committee Chair
Carlos D’Ancona Annual Meeting Chair
Do not miss this opportunity! ICS 2014, Rio de Janeiro - 20th - 24th October 2014
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VI COURSE URODYNAMICS WITHOUT MYSTERIES - School of Urodynamics Unicamp
Held in March 28 to 29, 2014, at Unicamp, with support from Dynamed, the course brought together professionals from various regions of the country to deepen the knowledge urodynamic. With a multidisciplinary profile with appearances by urologists, gynecologists, pediatric surgeons, physical therapists and nurses the course kept his practical and didactic. Tests in animals and intensive clinical case discussions were again the highlight of this event for six years without interruption brings news broadcasts and concepts related to urodynamic study. The course was organized by Porf. Carlos D'Ancona, Dr.Daniel Silva, Dr.Ricardo Miyaoka and Dr.Walter da Silva Jr.
Participants relied on computers throughout the course to work in real time with the clinical cases used during discussions.
Participants during the practical lesson: learning to avoid artifacts and conduct the investigation in accordance with the standardizations.
Divided into small groups and with continuous monitoring, participants might take practically all doubts and acquire new and important concepts.
Weekly meeting of Unicamp Urology Online!
The last weekly meeting of each month will be broadcast live from the 26th of February. This project aims to share knowledge and experiences with urologists from all over Brazil and the world. Do not miss this opportunity to discuss clinical cases, without leaving your home or office. Simply access the Urology Without Borders link and enter login (urologia) and password (semfronteiras).