Biomedical subjects
D A Levy
Publications and source records attributed to D A Levy.
Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma.
PURPOSE: We report stage specific followup guidelines based on our evaluation of the pattern of recurrence in 286 patients treated for local N0 or Nx renal cell carcinoma. MATERIALS AND METHODS: We retrospectively reviewed the clinical records of 286 patients with pT1 to pT3N0 or Nx renal cell carcinoma who underwent nephrectomy at our center between February 1985 and December 1994. In cases of later metastases the median interval to first metastasis, site of metastasis and method of diagnosis were correlated with the primary lesion stage. RESULTS: Metastases developed in 68 patients a median of 23 months after nephrectomy. Eight of the 113 patients with pT1 disease had metastases (median time to diagnosis 38 months), while 17 of 64 with pT2 disease and 43 of 109 with pT3 disease had metastases (medians 32 and 17 months, respectively). Of the 92 metastases 59 (64%) were asymptomatic, including 44 detected on routine chest x-rays (32) and blood tests (12). Isolated asymptomatic intra-abdominal metastases were diagnosed by surveillance computerized tomography in only 6 patients (9%). The remaining patients with metastases had associated clinical symptoms and/or abnormal results on interval tests that prompted further diagnostic studies. CONCLUSIONS: We confirmed that the risk of metastatic renal cell carcinoma is stage dependent. Therefore, surveillance protocols should be based on the pathological stage of the primary tumor. We recommend an annual chest x-ray, and serum liver function and alkaline phosphatase level tests for patients with pT1 disease. These studies are indicated beginning at 6 and 3 months for pT2 and pT3 disease, respectively, continuing every 6 months for 3 years and then annually. Surveillance computerized tomography should be performed at 24 and 60 months in patients with pT2 and pT3 disease or earlier when the results of any routine study are abnormal or clinical symptoms are present. Bone and brain surveillance studies should be prompted by site specific symptoms, elevated alkaline phosphatase levels or the diagnosis of metastasis at another site.
Timely delivery of biological therapy after cytoreductive nephrectomy in carefully selected patients with metastatic renal cell carcinoma.
PURPOSE: We determine whether cytoreductive surgery delays or precludes the administration of systemic biological therapy in patients with previously untreated metastatic renal cell carcinoma. MATERIALS AND METHODS: We evaluated 79 patients 22 to 73 years old with untreated renal cell carcinoma for possible cytoreductive surgery before the administration of systemic biological therapy. Based on performance status, overall disease burden and subjective clinical assessment 13 patients were referred for initial systemic biological therapy and 66 underwent cytoreductive surgery as initial treatment. We evaluated patient ability to receive postoperative biological therapy, time to therapy, surgical complications and mortality. RESULTS: Cytoreductive surgery had a minimal impact on the administration of timely systemic biological therapy in these carefully selected patients. Of the 66 patients 54 (82%) received postoperative systemic biological therapy beginning a median of 40 days after nephrectomy. Two patients (3%) died postoperatively (within 30 days) and in 1 (1.5%) postoperative deterioration in performance status precluded the administration of systemic therapy. The other 9 patients did not have measurable residual disease postoperatively, did not need or refused systemic therapy, or were followed elsewhere. CONCLUSIONS: Systemic biological therapy can be administered in a timely manner (median 40 days) to the majority of patients (82% treated) after cytoreductive surgery. Surgery alone does not preclude the administration of systemic biological therapy in carefully selected patients.
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Nephrectomy and vena caval thrombectomy in patients with metastatic renal cell carcinoma.
OBJECTIVES: To report out experience with performing nephrectomy and vena caval thombectomy in patients with metastatic renal cell carcinoma. METHODS: A retrospective review was performed of 15 patients who underwent surgical excision of the primary tumor and a caval thrombus and treatment of concurrent metastases between 1989 and 1995. The sites of metastases included lungs (n = 8), bone (n = 3), bulky retroperitoneal or mediastinal lymph nodes (n = 2), liver (n = 1), and contralateral adrenal (n = 1). The level of caval involvement was suprahepatic in 3 cases, retrohepatic in 2 cases, and infrahepatic in 10 cases. Three patients had an Eastern Cooperative Oncology Group performance score of 0, 11 had a score of 1, and 1 had a score of 2. Median follow-up was 17 months. RESULTS: Median operative time was 6.5 hours and median hospitalization was 10 days. Two patients required re-exploration for postoperative hemorrhage. There were no perioperative deaths. Four patients underwent surgery for resection of solitary metastases (1 lung, 2 spine, and 1 humerus); 2 of the 4 received adjuvant radiotherapy. Two patients received biologic therapy preoperatively, 3 received it both preoperatively and postoperatively, and 6 received it only postoperatively. The median time to initiation of postoperative biologic therapy was 48 days (range 25 to 110). Eleven patients are currently alive, 7 with no evidence of disease at a median follow-up of 17 months (range 6 to 66) and 4 with stable metastases at 14 months (range 4 to 22). Ten of the 13 symptomatic patients had improved performance scores after surgery. Four patients have died from metastatic disease: 2 from rapid progression at 2 and 5 months after surgery and the other 2 at 17 and 42 months. CONCLUSIONS: Nephrectomy and vena caval thrombectomy can be safely performed in selected patients with metastatic disease. Furthermore, in patients receiving biologic therapy, nephrectomy may enable a better quality of life and prolonged survival.
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The allergenic properties of fresh and preserved Hevea brasiliensis latex protein preparations.
The allergenic properties of the proteins of two lyophilized fractions of fresh natural rubber latex obtained by ultracentrifugation, the C serum and the sedimented bottom or lutoid fraction, have been compared with those of the serum proteins of two samples of high ammonia latex (HAL) [A]HALS obtained from HAL stored for more than 1 year, and [M]HALS derived from HAL stored for 6 weeks before ultracentrifugation and lyophilization. The most potent source of allergenic polypeptides both for skin prick testing of latex-sensitive patients and for immunoblots of their blood serum was the lutoid fraction of fresh latex. Skin prick tests and immunoblots of patients' sera showed that the allergenicity of the ammoniated latex decreased during storage. Skin prick tests using fractions of [A]HALS, C serum and lutoid proteins obtained after passage through a Sephacryl S300 column showed that the components of all three preparations which eluted in the largest volumes were almost equally effective in provoking the largest number of responses. Immunoblots of the sera of 43 latex-sensitive individuals showed that the majority (66%) of sera of the adult allergic patients reacted with a polypeptide of 19 kD. No characteristic pattern of binding latex polypeptides could be recognized in the sera from patients who were also asthmatic or from those who had an anaphylactic response to latex proteins.
Staging and prognosis of T3b bladder cancer.
Individuals with extravesical extension of bladder cancer (stage T3b) have a worse prognosis than those with muscle-invasive disease confined to the bladder. Accurate staging of T3b bladder cancer becomes increasingly important as more effective methods of treating high-stage bladder cancer are developed. Despite aggressive attempts over the last three decades to stage muscle invasive disease more accurately, bladder cancer is still staged incorrectly in 30% to 50% of patients. The basis for accurate clinical staging resides in a thorough endoscopic resection and a careful bimanual examination. Imaging studies (transurethral ultrasonography, computed tomography [CT], and magnetic resonance imaging [MRI] can increase the accuracy of staging but are most reliable when performed before transurethral resection.
Effect of human chorionic gonadotropin before spermatic vessel ligation in the prepubertal rat testis.
After single stage Fowler-Stephens orchiopexy testicular atrophy is common. Previous experimental study in the scrotal testis of the adult rat has shown that ligation of the internal spermatic artery often causes focal testicular infarction or atrophy and exogenous human chorionic gonadotropin increases testicular blood flow. We questioned whether division of the internal spermatic artery in the undescended rat testis would also cause testicular injury and hypothesized that these changes might be prevented by administering human chorionic gonadotropin before vessel ligation. Two groups of 20-day-old Sprague-Dawley male rats were subjected to unilateral internal spermatic artery ligation. Group 1 (control) received no human chorionic gonadotropin, while group 2 received 10 IU human chorionic gonadotropin daily from days 3 to 17 of life. At 3 months testicular blood flow was quantitated using 141cerium radioactive microspheres. The results indicated that blood flow on the operated side was lower than on the nonoperated side but the change was not statistically significant. Human chorionic gonadotropin had no effect on blood flow to the operated testes. Gross testicular weights of operated versus nonoperated gonads were similar in rats that did and did not receive human chorionic gonadotropin. Pathological evaluation revealed normal histology in all testes. These results do not support the use of human chorionic gonadotropin preoperatively to stimulate collateral testicular blood flow.
Simple narcotic kits for controlled-substance dispensing and accountability.
Operating rooms require a storage, dispensing and accounting system for restricted drugs which satisfies narcotics control authorities and is compatible with efficient care of patients. We describe narcotic kits containing fentanyl-morphine-midazolam, alfentanil-midazolam and sufentanil-midazolam, for general operating rooms, and two kits with larger quantities of fentanyl and sufentanil for cardiac operating rooms. The container for each kit is a video cassette holder which has a foam-rubber liner with sculpted depressions for each ampoule. Sealed kits are delivered each morning from pharmacy to the locked narcotics cupboard in the recovery room. On request, the recovery room nurse unlocks the cupboard and the anaesthetist signs out the required kit(s) for the day. A drug utilization form is enclosed with each kit, on which the anaesthetist records the amount of drug administered to each patient, and before returning the kit to the locked narcotics cupboard, the total amount of each drug used, discarded, and returned. Used kits are collected the following morning by a pharmacy technician who reconciles the contents and drug form of each kit. More than 40 staff anaesthetists and a similar number of residents have used the system for seven years, during which time 130,000 patients have passed through the operating rooms. Detection of one case of drug diversion by a staff anaesthetist was made partly by the control system, but mainly by behavioural changes. The system is simple, inexpensive, and effective and has been well received by the departments of pharmacy, anaesthesia, and nursing.
Neonatal testis tumors: a review of the Prepubertal Testis Tumor Registry.
Since 1980, 338 testis tumors have been registered in the Prepubertal Testis Tumor Registry of the American Academy of Pediatrics, Section on Urology. Of these tumors 22 occurred in neonates less than 1 month old, of which 7 (31%) were diagnosed at birth. The distribution of lesions in this group revealed 6 yolk sac tumors, 6 gonadal stromal tumors, 6 juvenile granulosa cell tumors, 2 gonadoblastomas, 1 teratoma and 1 hamartoma. Preoperative serum alpha-fetoprotein levels were available for 10 patients and ranged from 23 to 61,700 ng/ml., which is within normal limits. No patient had evidence of metastatic disease at presentation. Of the 18 children in whom follow up is available 17 have no evidence of disease and 1, who was diagnosed with a yolk sac tumor before the advent of chemotherapy, died of metastatic disease before reaching age 1 year. Although neonatal testis tumors are rare, they should be considered in the differential diagnosis and management of a newborn with a scrotal mass.
Laparoscopic pelvic lymphadenectomy and radical perineal prostatectomy: a viable alternative to radical retropubic prostatectomy.
Laparoscopic pelvic lymphadenectomy and radical perineal prostatectomy performed under the same anesthetic provide accurate surgical resection of localized carcinoma of the prostate with reduced intraoperative blood loss, minimal postoperative discomfort, short hospital stay (mean 4.1 days), high level of postoperative continence (81% completely dry after 4 months postoperatively) and low morbidity (4 complications). The clinical records of 37 patients undergoing this combined procedure during the last 22 months were reviewed retrospectively and the efficacy of the procedure was evaluated. This combined treatment modality avoids an abdominal incision and pelvic drains, and is associated with minimal postoperative discomfort and a short hospital stay. Laparoscopic pelvic lymphadenectomy combined with radical perineal prostatectomy is an alternative to open pelvic lymph node dissection and radical retropubic prostatectomy.
Psychologic symptoms in asthma and chronic urticaria.
Psychologic symptoms of 102 adult patients with asthma and 74 adult patients with chronic idiopathic urticaria, plus 252 normal nonclinical controls and 383 psychologically distressed ('socially isolated') but medically healthy adults were assessed by means of the Brief Symptom Inventory (BSI). On average, both asthma and urticaria patients had more psychopathology-evident in most symptom dimensions of the BSI-than healthy controls but much less than 'socially isolated' adults. Nevertheless, only about 40% of the subjects in both patient groups had above-normal BSI scores. Both men and women with asthma and women with urticaria had BSI scores greater than the normal controls, whereas the scores of men with urticaria were not different from those of healthy men. Thus, about half the women with either disease but less than one man in three with asthma and only about one man in ten with urticaria had significant psychologic distress. Recognition of patients' psychologic symptoms should be useful in planning and managing their medical therapy.
Purification of human IgG4 subclass with allergen-specific blocking activity.
Blocking antibodies (bAb) induced by allergen immunotherapy are restricted to the IgG1 and IgG4 subclasses, with IgG1 predominating early and IgG4 coming later. Study of IgG4 bAb has been limited, in part, by the absence of a method to purify IgG4. We describe a rapid immunoaffinity chromatographic method for the purification of that subclass from whole serum. Starting serum (TR) contained 90 micrograms/ml Dactylis glomerata (orchard grass) pollen (DGP)-specific IgG4, measured by indirect ELISA. The blocking activity of TR was assayed in vitro on IgE-sensitized human basophils. Immunoadsorption on a strong-binding anti-IgG4 monoclonal antibody (mAb) removed about 90% of the total and allergen-specific IgG4 and nearly all of the blocking activity from TR. An IgG4-rich fraction was then obtained by absorption of several small volumes of TR on a weak-binding anti-IgG4 mAb column at neutral pH followed by elution with glycine-HCl buffer. The pooled eluates contained 82% IgG4, amounting to a 65-fold purification of the serum IgG4; the yield was approximately 30%. Nearly all the DGP-specific antibody was in the IgG4 component of the eluate. The blocking activity of the eluate was approximately equal to that of TR. Immunoblot patterns with the eluate and with TR on SDS-PAGE of DGP were nearly identical. This method thus provides a fully active, relatively pure IgG4 blocking antibody. Moreover, the results reinforce the importance of using a well-chosen mAb when purifying proteins by immunoaffinity chromatography.
Giant multilocular prostatic cystadenoma: a rare clinical entity and review of the literature.
Giant multilocular prostatic cystadenoma is a pathologically benign entity. To our knowledge only 3 cases have been reported in the literature, of which 2 were treated by means of pelvic exenteration. These lesions can occur in men of various ages, arise from the prostate and grow to massive proportions. Histologically the tumor is comprised of benign cysts lined with cuboidal and columnar epithelium. The lesions do not invade contiguous structures but they can be adherent to viscera in their proximity. Giant multilocular prostatic cystadenoma as demonstrated by our case is a benign entity that can be definitively treated by carefully planned complete surgical excision.
Report of the International Latex Conference: sensitivity to latex in medical devices, Baltimore, Md., USA. 5-7 November, 1992.
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Allergy to latex. Introduction.
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