Tuesday, July 1, 2014

Historical Contribution: 1934, Waters, Lewis & Frontz, Radiotherapy for Renal Cancer


Hohman LB, Scott WW. A Combined Psychiatric and Urologic Study of Sexual Impotenct. Southern Medical Journal. 1933;29;1:59-76.

This manuscript starts with a case description, a 52 year-old man presents with a large renal mass, palpable "It is evident in this case we were dealing with an extremely radiosensitive tumor."  
through his abdomen, firm to the touch and extended 11cm beneath the margin of his ribs.  He was treated with external radiotherapy in preparation for surgery, but never came back to the hospital for nephrectomy.  He lived greater than 5 years without additional treatment, prompting the authors to conclude,

Today we know that renal cell carcinoma is actually an extremely radioresistant tumor.  However, this manuscript is a fascinating look into the understanding of renal cell carcinoma in 1934.  Here are some salient points made by the authors:

  • Radiation was often used in cases that were felt unresectable or in the presence of metastatic disease.  Marked reduction in the size of the primary tumor was observed in many of these cases.
    • Size reduction was almost immediate.
    • Delay in surgery resulted in regrowth of tumor.
    • Because imaging techniques were poor, response to radiation was measured by palpation.
  • "...the percentage of cures will probably not be materially increased until earlier diagnosis makes possible the institution of treatment before metastases has occurred."
    • hematuria as the first symptom should call for a thorough evaluation of the urinary tract.
  • Radiosensitivity is based on tumor cell type, with "tumors that revert to the embryonic type of growth and present a considerable degree of anaplasia are most radiosenstive" -- an observation made by Ewing.
    • Renal cortical tumors (hypernephromas) demonstrated a fair response with regard to size.
    • Renal pelvis tumors (papillary urothelial tumors) did not respond to radiation.
    • In addition, papillary renal cell carcinomas did not respond to radiation; "there were no areas of necrosis, no large cysts, and no blood-filled spaces."

  • Interestingly, necrosis was a common finding after irradiation - without a control group, it makes you wonder how many large, renal cortical tumors have necrosis as a baseline.
  • At the doses of radiation given, there were no changes to the normal renal parenchyma surrounding the tumors, but doses were limited by side effects: skin erythema and nausea.
    • However, extensive morphological changes were noted in the radiosensitive tumors with fibrosis, hyalinization and necrosis.  
  • The nephrectomy in patient case number 2 was performed by leaving "pedicle clamps" in place for 9 days after surgery before removing them - without an issue!
  • The authors highlight a number of important oncological principles of time (some still current):
    • minimize palpation of the tumor to prevent shedding of tumor cells
    • the renal pedicle should be ligated prior to manipulation (for the same reason)

Click here or on the link above to read the entire manuscript.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 


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