Avaliação do valor prognóstico da expressão imuno-histoquímica das proteínas renina, eritropoietina e catepsina D em pacientes portadores de carcinoma de células renais do tipo células claras / Analysis of the immunohistochemical expression and the prognostic value of renin, erythropoietin, and cathepsin D in patients with clear cell renal cell carcinoma

INTRODUÇÃO: Nas últimas décadas, houve uma migração do diagnóstico do carcinoma de células renais (CCR) para estádios mais precoces. Contudo, não houve uma concomitante redução das taxas de mortalidade. Características tumorais e relacionadas aos pacientes apresentam o maior impacto prognóstico, particularmente estádio clínico, tamanho tumoral, grau nuclear e subtipo histológico. No entanto, agrupá-las com outros parâmetros, inclusive biomoleculares, pode levar a uma análise mais acurada. OBJETIVO: Nosso objetivo foi avaliar a expressão imuno-histoquímica (IHQ) e o valor prognóstico da eritropoietina (EPO), da catepsina D (CTSD), além de entender se a expressão concomitante da renina (REN), com cada um desses dois marcadores, interfere nos desfechos oncológicos do CCR do tipo células claras (CCRcc) em pacientes não metastáticos. MATERIAL E MÉTODOS: Foram analisados dados de 729 pacientes com CCRcc submetidos a tratamento cirúrgico no A.C.Camargo Cancer Center entre 1985 e 2016. Todas as lâminas passaram por revisão anatomopatológica central por uropatologistas especializadas. Blocos de tissue microarray (TMA) foram construídos com amostras duplicadas de cada caso e as reações IHQ foram realizadas com clones de anticorpos previamente selecionados para REN, EPO e CTSD. As expressões de REN e EPO foram classificadas qualitativamente em "positiva" ou "negativa". A expressão da CTSD foi classificada em "expressão fraca ou ausente" ou "forte expressão". Foram analisadas associações com as variáveis clínicas e patológicas e as taxas de sobrevida global (SG), sobrevida câncer específica (SCE) e sobrevida livre de recorrência (SLR) em 10 anos. RESULTADOS: A REN mostrou-se positiva em 426 casos (70,6%) e negativa em 177 (29,4%). A expressão positiva de EPO ocorreu em 86,6% da amostra. Já a CTSD, apresentou expressão fraca ou ausente em 58,2% e expressão forte em 41,3% dos casos. A expressão de EPO não impactou os desfechos oncológicos, nem se associou com variáveis clínicas ou patológicas de destaque, mesmo quando analisada em conjunto com a expressão de REN. Esta última, quando ausente, associou-se com idade mais elevada, anemia pré-operatória, tamanho tumoral, infiltração de gordura perirrenal, hilo ou seio renal, invasão microvascular, necrose, alto grau nuclear de ISUP e estádio clínico III-IV. Por outro lado, a forte expressão de CTSD também se associou com várias dessas variáveis de pior prognóstico. A ausência de expressão IHQ de REN e a forte expressão de CTSD, tanto de modo isolado, como em conjunto, foram fatores preditores de pior SG e SCE em 10 anos. A ausência da primeira e, particularmente, a combinação dos dois fatores influenciaram negativamente também a SLR. CONCLUSÃO: Enquanto a EPO não demonstrou valor prognóstico neste estudo, a ausência de REN, a forte expressão de CTSD, além da combinação destes dois fatores, foram capazes de se associar com piores desfechos oncológicos no CCR não metastático

INTRODUCTION: In the last decades, it has been observed a stage migration in renal cell carcinoma (RCC). However, there was no concomitant reduction in mortality rates. The tumoral factors, such as the clinical stage, tumor size, nuclear grade, or histologic subtype, have been characterized as major predictors. Nonetheless, an improvement of this analysis can be achieved after combine them with other variables, including biomolecular factors. PURPOSE: To assess the immunohistochemical (IHC) expression and the prognostic value of erythropoietin (EPO) and cathepsin D (CTSD), besides evaluating if the concomitant expression of the previously studied protein renin (REN), with each one of the other markers, can influence the prognostic outcomes in non-metastatic patients. MATERIAL AND METHODS: A total of 729 patients with clear cell renal cell carcinoma (ccRCC) who underwent surgical treatment at A.C.Camargo Cancer Center between 1985 and 2016 were evaluated. All cases of the tumor bank were centrally reviewed by dedicated uropathologists. IHC expression patterns of the markers were assessed with a tissue microarray technique. REN and EPO were classified as "positive" or "negative expression". CTSD was grouped in "absent or weak expression" or "strong expression". Associations among clinical and pathological variables and the studied markers, besides of the 10-year overall survival (OS), cancer specific survival (CSS), and recurrence free survival (RFS) rates were described. RESULTS: The REN expression was positive in 426 (70.6%) cases, and the EPO positive expression was observed in 86.6%. It was evidenced an absent or weak expression of CTSD in 58.2%, and a strong expression in 41.3% of this cohort. EPO expression showed no impact on survival rates, even if concomitantly assessed with REN. The negative expression of REN associated with advanced age, preoperative anemia, larger tumors, perirenal fat, hilum or renal sinus infiltration, microvascular invasion, necrosis, high nuclear grade, and clinical stages III or IV. On the other hand, the strong expression of CTSD associated with poor prognostic variables. Both of these expression patterns of REN and CTSD were unfavorable predictors of 10-year OS and CSS. Particularly, the combination of negative REN and strong CTSD expression presented worse impact on these rates than the isolated analysis of each one, including a higher risk of recurrence. CONCLUSION: The loss of REN expression and the strong expression of CTSD were independent prognostic factors in non-metastatic ccRCC, particularly when the concomitant expression pattern of both markers is present. The immunohistochemical expression of EPO did not influence survival rates in this study.

Should obesity be associated with worse urinary continence outcomes after robotic-assisted radical prostatectomy? a propensity score matching analysis

ABSTRACT Purpose: To analyze the association between obesity and urinary incontinence rate in men submitted to robot-assisted radical prostatectomy (RARP) in a high-volume cancer center. Materials and Methods: We reported 1.077 men who underwent RARP as the primary treatment for localized prostate cancer from 2013 to 2017. Patients were classified as non-obese (normal BMI or overweight) or obese men (BMI ≥30kg/m2). They were grouped according to the age, PSA level, D'Amico risk group, Gleason score, ASA classification, pathological stage, prostate volume, salvage/adjuvant radiotherapy, perioperative complications, and follow-up time. Urinary continence was defined as the use of no pads. For the analysis of long-term urinary continence recovery, we conducted a 1:1 propensity-score matching to control confounders. Results: Among the obese patients, mean BMI was 32.8kg/m2, ranging 30 - 45.7kg/m2. Only 2% was morbidly obese. Obese presented more comorbidities and larger prostates. Median follow-up time was 15 months for the obese. Complications classified as Clavien ≥3 were reported in 5.6% of the obese and in 4.4% of the non-obese men (p=0.423). Median time for continence recovery was 4 months in both groups. In this analysis, HR was 0.989 for urinary continence recovery in obese (95%CI=0.789 - 1.240; p=0.927). Conclusions: Obese can safely undergo RARP with similar continence outcomes comparing to the non-obese men when performed by surgeons with a standardized operative technique. Future studies should perform a subgroup analysis regarding the association of obesity with other comorbidities, intending to optimize patient counseling.

Prostate Cancer Screening in Brazil: a single center experience in the public health system

ABSTRACT Purpose: Incidence and mortality of prostate cancer (PCa) are still increasing in developing countries. Limited access to the health system or more aggressive disease are potential reasons for this. Ethnic and social differences in developed countries seem to make inappropriate to extrapolate data from other centers. We aim to report the epidemiological profile of a PSA-screened population from a cancer center in Brazil. Materials and Methods: We retrospectively selected 9.692 men enrolled in a PCa prevention program, comprising total PSA level and digital rectal examination at the first appointment, associated with complementary tests when necessary. Men aged over 40 years-old were included after shared decision-making process. Prostate biopsy (TRUS) was performed when clinically suspected for PCa. After the diagnosis, patients underwent appropriate treatment. Results: TRUS was performed in 5.5% of men and PCa incidence was 2.6%. Overall ratio between number of patients who needed to be screened in order to diagnose one cancer was 38.9 patients, with 2.1 biopsies performed to diagnose a cancer. Positive predictive value (PPV) of TRUS biopsy in this strategy was 47.2%, varying from 38.5% (<50 years-old) to 60% (>80 years-old). We evidenced 70 patients (27.9%) classified as low risk tumors, 74 (29.5%) as intermediate risk, and 107 (42.6%) as high-risk disease. Conclusions: PSA-screening remains controversial in literature. In front of a huge miscegenated people and considering the big proportion of high-risk PCa, even in young men diagnosed with the disease, it is imperative to inform patients and health providers about these data particularities in Brazil.

Abdome agudo como manifestação inicial de melanoma metastático: relato de caso / Acute abdomen as initial manifestation of metastatic melanoma

The malignant melanoma is a relatively common neoplasia, with origin generally in the melanocytics cells in the skin, but with presentation of other possible primary lesions, being presented in this, a case witnessed of liver and mesentery metastases with unknown primary sites.

Tricobezoar retal: relato de um caso raro na literatura / Rectal trichobezoar: report of a rare case in literature

O bezoar compreende o acúmulo de substâncias não-digeríveis (folhas, pêlos, pedras, produtos lácteos, medicamentos, entre outros) no trato digestório. Sua importância deve-se ao quadro clínico por vezes inespecífico e às complicações que podem surgir. Apresentamos aqui o caso de uma paciente de 62 anos atendida no serviço de Cirurgia Oncológica com quadro de um mês de evolução e suspeita inicial de neoplasia colorretal. Exames complementares não elucidaram o diagnóstico, que só foi feito após abordagem cirúrgica por laparotomia exploratória. Após a mesma, a paciente evoluiu com piora do estado geral e foi transferida para a UTI do hospital, falecendo devido a complicações septicêmicas. Esse caso demonstra as dificuldades para se chegar nesse diagnóstico e que o atraso pode resultar em complicações letais para o paciente.

Bezoar is a foreign body in the digestive tract originated from ingestion of non-digestible substances (leaves, hair, rocks, milk products, drugs, etc). Undetermined clinical signs and severe complications make it an important diagnosis. We report the case of a 62-year-old female patient who was seen at the oncological surgery department of Santa Casa de Misericórdia de Fortaleza. The patient reported having low gastrointestinal symptoms for a month. Colorectal neoplasia was initially suspected. Blood and image diagnostic tests were not elucidative. The diagnosis was just confirmed after surgical approach. The patient had a poor postoperative follow-up and died after complications of septicemia. This case demonstrates the difficulties to confirm such diagnosis and the lethal complications caused by diagnosis delay.