Male urethral sarcoma: a case report and literature review / Sarcoma de uretra masculina: relato de caso e revisão de literatura

Urethral tumors are rare and aggressive. They usually affect men (2:1) and occur more commonly in white (85% of cases). Soft tissue sarcomas are a heterogeneous group of tumors that arise from embryonic mesoderm. It represents 1% of all cases of urinary tract malignancies and rarely primary affect the ureter. We report a case of male urethral sarcoma. To date, only two similar cases have been published in literature.

Os tumores de uretra são muito raros e bastante agressivos. Acometem mais frequentemente homens (2:1) e são mais comuns na raça branca (85% dos casos). Os sarcomas de tecidos moles são um grupo heterogêneo de tumores que surgem a partir da mesoderme embrionária e representam 1% de todos os casos de doença maligna urinária, raramente acometendo a uretra primariamente. Relamos aqui um caso extremamente raro de sarcoma uretral masculino com somente dois semelhantes publicados na literatura.

Biochemical recurrence rates are similar for pT2-positive surgical margins and pT3a

Objective Histological details of positive surgical margins in radical prostatectomy specimens have been related to outcome after surgery in rare studies recently published. Our objective is to assess whether the status of surgical margins, the extent and the Gleason score of positive margins, and the extent of the extraprostatic extension are predictive of biochemical recurrence post-radical prostatectomy.Materials and Methods Three hundred sixty-five radical prostatectomy specimens were analyzed. The length of the positive surgical margin and extraprostatic extension and the Gleason score of the margin were recorded. Statistical analyses examined the predictive value of these variables for biochemical recurrence.Results 236 patients were stage pT2R0, 58 pT2R1, 25 pT3R0 and 46 pT3R1. Biochemical recurrence occurred in 11%, 31%, 20% and 45.7% of pT2R0, pT2R1, pT3R0 and pT3R1, respectively. The extent of the positive surgical margins and the Gleason score of the positive surgical margins were not associated with biochemical recurrence in univariate analysis in a mean follow up period of 35.9 months. In multivariate analyses, only the status of the surgical margins and the global Gleason score were associated with biochemical recurrence, with a risk of recurrence of 3.1 for positive surgical margins and of 3.8 for a Gleason score > 7.Conclusion Positive surgical margin and the global Gleason score are significant risk factors for biochemical recurrence post-radical prostatectomy, regardless of the extent of the surgical margin, the extent of the extraprostatic extension, or the local Gleason score of the positive surgical margin or extraprostatic tissue. pT2R1 disease behaves as pT3R0 and should be treated similarly.

Recurrence of acute myeloid leukemia in cryptorchid testis: case report / Recidiva de leucemia mieloide aguda em testículo criptorquídico: relato de caso

A 23-year-old male with a history of bone marrow transplant for acute myeloid leukemia. He presented a large mass in the right inguinal region 5 years ago. Upon physical examination, right-sided cryptorchidism was observed. The tumor markers alpha-fetoprotein and beta-HCG were within normalcy range and lactate dehydrogenase was raised. Computed tomography of the abdomen and pelvis revealed right testicular mass in contiguity with the inguinal canal to the ipsilateral retroperitoneum, associated with right hydronephrosis. Due to the risk of germ-cell tumor in undescended testicle, the patient underwent radical right orchiectomy. The pathological examination showed recurrence of acute myeloid leukemia in the testis. He was referred to oncology for adjuvant therapy. Our literature review found no similar cases described.

Paciente de 23 anos, masculino, com antecedente de transplante de medula óssea por leucemia mieloide aguda. Há 5 anos, apresentou volumosa massa em região inguinal direita. No exame físico, foi constatada criptorquidia à direita. Os marcadores tumorais alfa-fetoproteína e beta-HCG encontravam-se dentro da normalidade, e a desidrogenase láctica estava aumentada. A tomografia computadorizada de abdomen e pelve revelou massa testicular direita com contiguidade pelo canal inguinal, até o retroperitônio ipsilateral, associada a hidronefrose direita. Devido ao alto risco de neoplasia germinativa em testículo criptorquídico, o paciente foi submetido à orquiectomia radical direita, cujo anatomopatológico revelou recidiva de leucemia mieloide aguda em testículo. Foi encaminhado para oncologia para terapia adjuvante. Nossa revisão não revelou nenhum caso semelhante na literatura.

Practical aspects of the use of FMEA tool in clinical laboratory risk management / Aspectos práticos da utilização da ferramenta FMEA na gestão de riscos do laboratório clínico

INTRODUCTION: This paper presents the failure modes and effects analysis (FMEA) tool in a clinical laboratory through the introduction of new technology for blood gas and serum ionized calcium in multi-parameter analyzers such as Point of Care Testing (POCT). OBJECTIVE: To present FMEA as a tool for risk managing and improvement with the introduction of new technologies in a public laboratory. METHODS: The change of multiparameter gas analyzer type POCT was defined and described as a process. Subsequently, the criteria were presented to the risk assessment and its quantification. We studied the failure modes that might occur in this process. We established three action plans involving improvements to be made in the technological change. FMEA was applied in two stages: at the beginning of the project and after the implementation of the proposed measures. RESULTS: The first plan involved administrative measures related to the bidding process; the second preventive action involved the possibility of which supplier would win the bid by studying the efficiency of the analyzer and its impact on productivity; the third set of actions was directed to improvements in the relationship with the clinical staff in order to minimize occasional complaints. The last actions referred to employing new employees to meet the growing demand. CONCLUSION: FMEA proved to be a reliable tool for performance improvement, which proactively identifies, prioritizes and mitigates patient risks.

INTRODUÇÃO: O artigo apresenta a ferramenta de análise do modo e do efeito de falhas (FMEA) dentro de um laboratório clínico por meio da introdução de nova tecnologia para gasometria e cálcio iônico sérico em analisadores multiparâmetros do tipo testes laboratoriais remotos (TLR) ou point of care testing (POCT). OBJETIVO: Apresentar a FMEA como ferramenta de gestão de riscos e de melhoria em um laboratório público ao introduzir novas tecnologias. MÉTODOS: A mudança de analisadores de gases multiparâmetros do tipo POCT foi definida e descrita como um processo. A seguir, foram apresentados os critérios para a avaliação dos riscos e a sua quantificação. Foram estudados os modos de falha pelos quais algo poderia falhar nos componentes desse processo. Estabeleceram-se três planos de ações que envolviam melhorias a serem introduzidas na mudança de tecnologia. A FMEA foi aplicada em dois momentos: no início do projeto e após a implantação das medidas propostas. RESULTADOS: O primeiro plano envolveu medidas administrativas vinculadas ao processo licitatório; a segunda ação preventiva envolveu a possibilidade de qual fornecedor venceria a licitação, estudando-se a eficiência do analisador e seu impacto na produtividade; o terceiro conjunto de ações foi dirigido às melhorias no relacionamento com o corpo clínico para minimizar as eventuais reclamações. As últimas ações referiram-se à contratação de novos funcionários para atender à demanda crescente. CONCLUSÃO: A FMEA revelou-se um instrumento de melhoria de desempenho para o laboratório, que de maneira proativa identifica, prioriza e mitiga os riscos do paciente.

Can we predict which patients will evolve to chronic kidney disease after nephrectomy for cortical renal tumors?

INTRODUCTION: While some studies show that patients submitted to radical nephrectomy have a higher risk of developing chronic kidney disease (CKD), some studies report that carefully selected living kidney donors do not present a higher risk for CKD. Here, we aim to study predictive factors of CKD after radical nephrectomy. MATERIALS AND METHODS: Between January 2006 to January 2010, 107 patients submitted to radical nephrectomy for cortical renal tumors at our institution were enrolled in this study. Demographic data were recorded, modified Charlson-Romano Index was calculated, and creatinine clearance was estimated using abbreviated Modification of Diet in Renal Disease (MDRD) study equation. Pathological characteristics, surgical access and surgical complications were also reviewed. The end-point of the current study was new onset estimated glomerular filtration rate (eGFR) less than 60 and less than 45 mL/minute/1.73 m². RESULTS: Age, preoperative eGFR, Charlson-Romano Index and hypertension were predictive factors of renal function loss, when the end-point considered was eGFR lower than 60 mL/minute/1.73 m². Age and preoperative eGFR were predictive factors of renal function loss, when the end-point considered was eGFR lower than 45 mL/minute/1.73 m². Moreover, each year older increased 1.1 times the risk of eGFR lower than 60 and 45 mL/minute/1.73 m². After multivariate logistic regression, only age remained as an independent predictive factor of eGFR loss. CONCLUSION: Age is an independent predictive factor of GFR loss for patients submitted to radical nephrectomy for cortical renal tumors.

Abscesso perineal por ingestão acidental de palito de dente / Perineal abscess for accidental ingestion of toothpick

Palitos de dente são itens domésticos comuns e a maioria das pessoas subestima a gravidade das lesões que podem ocorrer com a ingestão acidental de palitos. Nós apresentamos um caso de abscesso perineal causado pela ingestão de um palito de dente. Um homem de 55 anos apresentou-se com quadro de dor perianal há um mês. Ao exame físico, notou-se abscesso perineal. Leucocitose com desvio à esquerda foi observada e a tomografia pélvica demonstrou um corpo estranho na região perineal. A remoção cirúrgica do corpo estranho e a drenagem adequada do abscesso foram realizadas, revelando um palito de dente. O paciente evoluiu bem após a abordagem cirúrgica. O abscesso perineal pode progredir para gangrena de Fournier e, portanto, a abordagem de abscessos perineais deve ser agressiva, com drenagem adequada e remoção do corpo estranho (sempre que presente).

Desdiferenciação do câncer da próstata após terapia antiandrogênica / Prostate cancer dedifferentiation following antiandrogen therapy: a morphological finding or an increased tumor aggressiveness?

OBJETIVO: O bloqueio androgênico neo-adjuvante em câncer da próstata produz involução do volume tumoral sem melhorar a evolução desses pacientes. Uma das explicações para esse fenômeno é a aquisição de comportamento mais agressivo pelas células tumorais remanescentes que, morfologicamente, apresentam aspecto mais indiferenciado após o bloqueio androgênico. Os objetivos do presente estudo foram avaliar a freqüência de desdiferenciação celular após tratamento antiandrogênico e definir se a neoplasia remanescente apresenta sinais de maior agressividade biológica. MÉTODOS: Trinta pacientes portadores de câncer da próstata localmente avançado foram submetidos a tratamento antiandrogênico neo-adjuvante por quatro meses, seguido de prostatectomia radical. Foram comparados os escores de Gleason da biópsia e do espécime cirúrgico. Ademais, mediu-se o índice de proliferação celular, determinado por imunohistoquímica para o PCNA, sendo considerados positivos os testes com reação nuclear intensa. A porcentagem de núcleos positivos, determinada em 500 células, foi confrontada com as diversas categorias do escore de Gleason do espécime cirúrgico. RESULTADOS: Em 11 espécimes cirúrgicos (37 por cento) o escore de Gleason foi igual ou menor que o encontrado na biópsia, enquanto em 19 (63 por cento) o escore cirúrgico foi maior que o da biópsia (p <0,05). A mediana de expressão do PCNA foi, respectivamente, de 4,5 por cento, 10 por cento, 12 por cento e 14 por cento para os escores de Gleason 2-4, 5-6, 7 e 8-10 (p> 0,05). A mediana dos índices de proliferação celular foi de 9 por cento para tumores confinados à glândula ou ao espécime e de 17 por cento para os extraprostáticos (p<0,05). CONCLUSÃO: Piora do escore de Gleason ocorreu em cerca de dois terços dos pacientes submetidos a tratamento hormonal anti-androgênico. Entretanto, os índices de proliferação celular, medidos pelo PCNA, foram iguais para espécimes com diferentes escores de Gleason. É provável que o bloqueio hormonal neo-adjuvante produza uma piora morfológica da neoplasia, sem, contudo, gerar clones celulares mais agressivos.

Sarcomatoid differentiation in renal cell carcinoma: prognostic implications

INTRODUCTION: Renal cell carcinoma with sarcomatoid differentiation is a tumor with aggressive behavior that is poorly responsive to immunotherapy. The objective of this study is to report our experience in the treatment of 15 patients with this tumor. MATERIALS AND METHODS: We retrospectively analyzed 15 consecutive cases of renal cell carcinoma with sarcomatoid differentiation diagnosed between 1991 and 2003. The clinical presentation and the pathological stage were assessed, as were the tumor's pathological features, use of adjuvant immunotherapy and survival. The study's primary end-point was to assess survival of these individuals. RESULTS: The sample included 8 women and 7 men with mean age of 63 years (44 - 80); follow-up ranged from 1 to 100 months (mean 34). Upon presentation, 87 percent were symptomatic and 4 individuals had metastatic disease. Mean tumor size was 9.5 cm (4 - 24) with the following pathological stages: 7 percent pT1, 7 percent pT2, 33 percent pT3, and 53 percent pT4. The pathological features showed high-grade tumors with tumoral necrosis in 87 percent of the lesions and 80 percent of intratumoral microvascular invasion. Disease-free and cancer-specific survival rates were 40 and 46 percent respectively, with 2 cases responding to adjuvant immunotherapy. CONCLUSIONS: Patients with sarcomatoid tumors of the kidney have a low life expectancy, and sometimes surgical resection associated with immunotherapy can lead to a long-lasting therapeutic response.

Prognostic value of the percentage of positive fragments in biopsies from patients with localized prostate cancer

OBJECTIVE: To assess the prognostic value of the percentage of positive fragments (PPF) in biopsies from patients with localized prostate cancer (PCa) undergoing radical prostatectomy. MATERIALS AND METHODS: During the period from March 1991 to November 2000, 440 patients were selected. Cases receiving neoadjuvant or adjuvant hormone therapy, or adjuvant radiotherapy, were excluded, as were cases presenting Gleason scores higher than 6 at biopsy. PPF was defined as the total number of fragments divided by the total number of biopsy fragments times 100. This variable was initially divided into categories from 0 to 25 percent, 25.1 percent to 50 percent, 50.1 to 75 percent and 75 percent to 100 percent. During the postoperative period, patients were assessed every 2 months for 1 year, then every 6 months for 5 years, and then yearly. Biochemical recurrence was defined as serum PSA higher than or equal to 0.4 ng/mL. Median follow-up was 60 months. RESULTS: One hundred and nine (24.8 percent) of the 440 patients under study had biochemical recurrence. In the univariate analysis, PPF significantly influenced disease-free survival (log-rank, p < 0.001), and patients with PPF between 75 and 100 percent presented a risk of a biochemical recurrence of the disease 3 times higher than patients with PPF between 0 and 25 percent (p < 0.001). After the Cox regression analysis, both serum PSA (p = 0.001) and PPF (p < 0.001) showed to be independent predictive factors for disease-free survival following surgery. CONCLUSION: PPF measurement in biopsy is a simple and practical method, which should be routinely used as a predictive factor for biochemical recurrence in patients with PCa presenting Gleason scores between 2 and 6.

Analysis of risk factors of involvement of seminal vesicles in patients with prostate cancer undergoing radical prostatectomy

OBJECTIVE: To determine through preoperative serum PSA level, Gleason score on biopsy and percentage of fragments affected by tumor on biopsy, the probability of involvement of the seminal vesicles. MATERIALS AND METHODS: During the period between March 1991 to December 2002, we selected 899 patients undergoing radical prostatectomy for treatment of localized prostate adenocarcinoma. The analyzed preoperative variables were PSA, percentage of positive fragments and Gleason score on the biopsy. Pre-operative PSA was divided in scales from 0 to 4.0 ng/mL, 4.1 to 10 ng/mL, 10.1 to 20 ng/mL and > 20 ng/mL, Gleason score was categorized in scales from 2 to 6. 7 and 8 to 10, and the percentage of affected fragments was divided in 0 to 25 percent, 25.1 percent to 50 percent, 50.1 percent to 75 percent, and 75.1 percent to 100 percent. All these variables were correlated with the involvement of seminal vesicles in the surgical specimen. RESULTS: Of the 899 patients under study, approximately 11 percent (95 percent CI, [9 percent - 13 percent]) had involvement of seminal vesicles. On the multivariate analysis, when PSA was < 4, the Gleason score was 2 to 6, and less than 25 percent of fragments were involved on the biopsy, only 3.6 percent, 7.6 percent and 6.2 percent of patients respectively, had involvement of seminal vesicles. On the multivariate analysis, we observed that PSA, Gleason score and the percentage of involved fragments were independent prognostic factors for invasion of seminal vesicles. CONCLUSION: The preoperative variables used in the present study allow the identification of men with minimal risk (lower than 5 percent) if involvement of seminal vesicles.

Nomograma para prever extensão da doença em adenocarcinoma da próstata: um estudo brasileiro / Nomodram to predict disease extension in prostate adenocarcinoma: a brazilian study

A necessidade de se definir a extensão da doença em pacientes que submetidos a prostatectomia radical por adenocarcinoma da próstata é fator relevante para cura destes indivíduos. Com o objetivo de identificar fatores pré-operatórios independentes para prever extensão do câncer da próstata, avaliou-se, retrospectivamente, o possível papel do nível sérico de PSA, da porcentagem de fragmentos positivos na biópsia, do escore de Gleason da biópsia e do estádio clínico. Esses parâmetros foram comparados com a extensão da doença definida pelo anatomopatógico da peça cirúrgica de 898 pacientes submetidos a prostatectomia radical por câncer clinicamente localizado de próstata. Na análise univariada e multivariada os quatro parâmetros estudados demonstraram significância estatística para prever doença confinada, encontrada em 66,7 por cento dos casos estudados. Observou-se ainda, que casos com escore de Gleason 7 tiveram o mesmo comportamento que casos com escore 8 a 10, quanto à extensão da doença (p=0,970). Estes resultados permitiram forjar o primeiro nomograma com homens brasileiros, utilizando os níveis séricos de PSA pré-operatório, a porcentagem de fragmentos positivos na biópsia e o escore de Gleason da biópsia para prever doença confinada. Concluímos que o uso de nomograma combinando esses parâmetros, possui maior acúracia para prever a extensão da doença do que a utilização de cada um deles isoladamente