Nephrectomy for Metastatic Renal-Cell Cancer

Metastatic renal-cell cancer resists cytotoxic chemotherapy and radiotherapy but can respond to various forms of immunotherapy. This prospective, randomized trial found that nephrectomy plus immunotherapy with interferon alfa-2b can prolong survival over that with immunotherapy alone.

The benefit of nephrectomy was significant, but not dramatic: the median survival of patients treated with nephrectomy followed by interferon was three months longer than that of patients who received interferon alone. Moreover, at one year, only 8 percent of all the study patients were alive. The grim prognosis of metastatic renal-cell cancer justifies the investigation of any plausible new treatment.

Related Editorial

Fluconazole Prophylaxis in Preterm Infants

Invasive fungal infections cause substantial morbidity and mortality in preterm infants. In this single-center, double-blind, placebo-controlled trial, extremely-low-birth-weight preterm infants who were given the antifungal agent fluconazole prophylactically for six weeks had significantly lower rates of fungal colonization and systemic fungal infection than control infants, without development of resistance to fluconazole or adverse effects on liver enzymes.

The prophylactic use of fluconazole can safely reduce the incidence of invasive fungal infection in extremely-low-birth-weight preterm infants. This intervention warrants further study in other centers.

Valsartan, an Angiotensin-Receptor Blocker, in Chronic Heart Failure

Angiotensin II may contribute to the progression of heart failure. In this trial, valsartan, an angiotensin-receptor blocker, reduced the need for hospitalization for heart failure but had no effect on overall mortality. According to a post hoc analysis, patients treated with valsartan who were also receiving both an angiotensin-converting–enzyme (ACE) inhibitor and a beta-blocker had increased mortality; patients receiving one or neither of these types of drugs had reduced mortality.

The finding that valsartan reduced the need for hospitalization among patients with heart failure is tempered by the results of a post hoc analysis indicating that patients already receiving treatment with an ACE inhibitor and a beta-blocker had higher mortality rates with valsartan. Other trials in progress are expected to clarify further whether angiotensin-receptor blockers have a central role in the treatment of heart failure.

Clinical Practice: Cardiac Risks of Noncardiac Surgery

A 65-year-old man requires resection of an abdominal aortic aneurysm. He has a remote history of myocardial infarction and rare episodes of angina. Recent coronary angiography revealed more than 70 percent stenosis of the left circumflex artery. What can be done to minimize this patient's risk of perioperative cardiac complications?

Current Concepts: Mesenteric Venous Thrombosis

Mesenteric venous thrombosis usually involves the superior mesenteric vein, with the danger of bowel infarction. The newer imaging techniques allow earlier diagnosis. A predisposing condition (such as a prothrombotic state, pancreatitis, and recent abdominal surgery) can be identified in most patients. Treatment involves anticoagulation, and surgery may be avoided if the correct diagnosis is made early.

Mechanisms of Disease: Aldosterone in Congestive Heart Failure

The potent mineralocorticoid aldosterone has a multifaceted role in the pathogenesis of congestive heart failure. In addition to its contribution to salt and water retention, it also promotes organ fibrosis. Although angiotensin-converting–enzyme inhibitors have important therapeutic benefit in heart failure, they do not eliminate the effects of aldosterone. Thus, recent studies have underscored the value of aldosterone-receptor antagonists, such as spironolactone, in the treatment of chronic heart failure. This review article gives an in-depth update on the mechanisms of action of aldosterone and their implications for therapy.

HOME  |  SUBSCRIBE  |  SEARCH  |  CURRENT ISSUE  |  PAST ISSUES  |  COLLECTIONS  |  PRIVACY  |  TERMS OF USE  |  HELP  |  beta.nejm.org

Comments and questions? Please contact us.

The New England Journal of Medicine is owned, published, and copyrighted © 2009 Massachusetts Medical Society. All rights reserved.