Functional Adrenocortical Carcinoma: A Rare Case With Thrombus Extension Into the Inferior Vena Cava and a Presentation of Cushing Syndrome.

Adrenocortical carcinoma (ACC) is a rare, highly malignant endocrine tumor, often associated with a poor prognosis. Most patients who develop ACC are either children of ages 1-6, or adults in their fourth to fifth decade of life. Individuals with a functional cortisol-secreting ACC frequently present with Cushing syndrome. We report a case of an 18-year-old male who was found to have a large ACC tumor, with thrombus extension into the inferior vena cava (IVC), after presenting with Cushing syndrome. ACC presents a challenging scenario for physicians as surgical resection remains the only form of curative therapy, however, despite such treatment many patients quickly develop metastases.

Cavernous hemangioma of the adrenal gland mimicking a hepatic hemangioma.

Adrenal cavernous hemangiomas are a rare, benign, and non-functional tumor. We report a case of a 62-year-old male who presented with right upper quadrant and flank pain. Physical examination revealed a fullness of the right upper quadrant. Both computed tomography and magnetic resonance imaging suggested a hemangioma originating from the liver. During angiography with the intent of embolization, it was discovered that the vascular supply was consistent with an adrenal mass rather than a hepatic origin. The patient was referred to Urology and underwent curative right open adrenalectomy and nephrectomy. Histopathology confirmed the diagnosis of an adrenal cavernous hemangioma.

Outcome analysis of patients with Peyronie's disease who elect for vacuum erection device therapy.

INTRODUCTION: Peyronie's disease (PD) affects approximately 0.7-11% of men and has numerous proposed treatments. Invasive management options include surgical or injectable therapy, while penile traction therapy with vacuum erection device (VED) represents a non-invasive approach. Our objective is to assess outcomes for patients with PD who opt for non-invasive management. METHODS: We performed a retrospective analysis for patients with PD who were followed for at least three months and opted for noninvasive therapy. All patients were instructed to initiate VED traction therapy for 10 minutes twice per day. Patients were assessed for degree of PD deformity and erectile function (Sexual Health Inventory for Men [SHIM] score) at initial and subsequent encounters. RESULTS: Fifty-three patients met the inclusion criteria. The mean (standard deviation [SD]) age was 57 (12) years, and the mean (SD) duration of PD prior to assessment was 25 (15) months. The mean (SD) duration of followup was 14 (11) months. Among untreated patients who did not use a VED, nine showed improvement, 20 remained stable, and four had worsening curvature. The untreated group had a significant change in curvature, with a mean improvement (SD) of 3.6 (12)° (p=0.048). All 20 men who initiated VED traction therapy had an improvement in curvature with a significant mean (SD) improvement of 23 (16)° (p=2.6×10-6). Changes in SHIM scores did vary significantly between groups. No complications were noted. CONCLUSIONS: In patients who opt for non-invasive management of PD, VED traction therapy provides improved curvature resolution compared to those who do not use such a device. The limitations of this study include the retrospective nature and a small sample size at a single treatment center.

An Examination of the Relationship between Mental Distress, Functional and Psychosocial Quality of Life Indicators in a Population Based Sample of Prostate Cancer Survivors Who Received Curative Treatment.

INTRODUCTION: Although survival rates are highest among prostate cancer survivors compared to any other forms of cancer, nearly 60% suffer from mental distress. Here we examine urinary function and psychosocial stressors and their association with poor mental health in a younger group of prostate cancer survivors who have undergone curative treatment. METHODS: The study includes 128 men (47 to 70 years old) who received active treatment for prostate cancer, and completed a survivorship online survey between 2017 and 2018. Psychological distress was assessed with Kessler Psychological Distress Scale. International Prostate Symptom Score subscales (incomplete urinary emptying, frequency, intermittency, urgency, weak stream, straining and nocturia) and number of current prostate cancer survivorship stressors were predictors. Multivariate logistic regression was used to fit the model while controlling for months of survivorship since diagnosis, the presence or absence of surgery, radiation or hormone therapy treatment, current medication for depression and demographics. RESULTS: A total of 19.5% of men scored positive for current mental health issues. Prostate cancer survivors who reported increased number of current survivorship stressors (OR 1.48, 95% CI 1.09-2.01), had higher frequency of urination (OR 2.05, 95% CI 1.15-3.64), history of radiation treatment (OR 7.15, 95% CI 1.02-50.35) and were currently on prescribed medication for depression (OR 33.47, 95% CI 3.80-294.87) had higher odds for screening positive for psychological distress compared with their counterparts. CONCLUSIONS: These results corroborate recent findings showing an intersection between urological oncology and poor mental health during survivorship, and warrant the development of multidisciplinary teams in addressing survivorship issues in this population.

Classification tree for the prediction of malignant disease and the prediction of non-diagnostic biopsies in patients with small renal masses.

INTRODUCTION: Preoperative prediction of benign vs. malignant small renal masses (SRMs) remains a challenge. This study: 1) validates our previously published classification tree (CT) with an external cohort; 2) creates a new CT with the combined cohort; and 3) evaluates the RENAL and PADUA scoring systems for prediction of malignancy. METHODS: This study includes a total of 818 patients with renal masses; 395 underwent surgical resection and 423 underwent biopsy. A CT to predict benign disease was developed using patient and tumour characteristics from the 709 eligible participants. Our CT is based on four parameters: tumour volume, symptoms, gender, and symptomatology. CART modelling was also used to determine if RENAL and PADUA scoring could predict malignancy. RESULTS: When externally validated with the surgical cohort, the predictive accuracy of the old CT dropped. However, by combining the cohorts and creating a new CT, the predictive accuracy increased from 74% to 87% (95% confidence interval 0.84-0.89). RENAL and PADUA score alone were not predictive of malignancy. One limitation was the lack of available histological data from the biopsy series. CONCLUSIONS: The validated old CT and new combined-cohort CT have a predictive value greater than currently published nomograms and single-biopsy cohorts. Overall, RENAL and PADUA scores were not able to predict malignancy.

Clinical follow up and the impact of the Paris system in the assessment of patients with atypical urine cytology.

BACKGROUND: Urinary cytology is routinely used in the diagnosis of urothelial neoplasms, with good sensitivity for high-grade urothelial carcinoma (HGUC) but less so for low-grade urothelial neoplasm (LGUN). There is significant interobserver and interinstitutional variability, especially for the atypical category. The Paris system for reporting urinary cytology (TPS) was introduced to better define the various categories, especially atypical cytology. METHODS: We retrospectively reviewed 630 atypia of undetermined significance (AUS) cases and reclassified them based on TPS. In total, 501 cases previously reported as negative for malignancy had their medical records reviewed to serve as negative controls. RESULTS: Of 630 AUS cases, 299 (47.5%) were reclassified as negative for HGUC (NHGUC), 313 (49.7%) as atypical urothelial cells (AUCs) and 18 (2.9%) as suspicious for HGUC (SHGUC). Based on our institution's previous reporting system, the rate of underlying or subsequent HGUC was 2.8% for AUS, and 0% for negative. When AUS cases were reclassified under TPS, the rates were 1.5% for NHGUC, 4.8% for AUC, and 0% for SHGUC. Review of medical records showed that patients with AUS were more likely to be followed-up compared with those with negative urine cytology (77.8% compared with 54.3%), particularly those under the care of non-urologists. CONCLUSIONS: AUS diagnosis is associated with more patient follow up compared with NEG urine particularly among non-urologists. Reclassifying according to TPS results in significant reduction in the rate of AUS and thus unnecessary testing. This reduction however may be at the expense of slightly decreased detection rate of HGUC.

Oncocytic adrenocortical carcinoma: a rare adrenal tumor subtype.

Oncocytic tumors arising from the adrenal gland are rare. Oncocytic adrenal neoplasms (OAN) may mimic adrenocortical carcinoma (ACC) at presentation, and can only be definitively diagnosed histologically. Most OANs are benign, and carry a favorable prognosis. We report on an 83-year-old female who, while being investigated for anemia and weight loss, was found to have a 23 cm adrenal mass concerning for ACC. Adrenalectomy and histopathology confirmed a malignant OAN, based on the Lin-Weiss-Bisceglia criteria. We report on the largest non-functional, malignant OAN cited in the literature to date. OAN's, though rare, can be considered in the differential diagnosis of large adrenal tumors.

Gravity-assisted drainage imaging in the assessment of pediatric hydronephrosis.

INTRODUCTION: As early detection of hydronephrosis increases, we require better methods of distinguishing between pediatric patients who require pyeloplasty vs. those with transient obstruction. Gravity-assisted drainage (GAD) as part of a standardized diuretic renography protocol has been suggested as a simple and safe method to differentiate patients. METHODS: Renal scans of 89 subjects with 121 hydronephrotic renal units between January 2004 and March 2007 were identified and analyzed. RESULTS: Of all renal units, 65% showed obstruction. GAD maneuver resulted in significant residual tracer drainage in eight renal units, moderate drainage in 12 renal units, and some improvement in 40 units after the GAD maneuver. Of the eight renal units with significant residual tracer drainage, only two proceeded to pyeloplasty. After pyeloplasty, nine children had improved time to half maximum (T(1/2) Max) and 13 were unchanged. CONCLUSIONS: Our study was limited due to its retrospective design and descriptive analyses, but includes a sufficient number of subjects to conclude that GAD as part of a diuretic renography protocol is an effective and simple technique that can help prevent unnecessary surgical procedures in pediatric patients.

Epigenetics application in the diagnosis and treatment of bladder cancer.

INTRODUCTION: Bladder cancer is the sixth most common cancer in the Western world. Patients with bladder cancer require close monitoring, which may include frequent cystoscopy and urine cytology. Such monitoring results in significant health care cost. The application of epigenetics may allow for a risk adapted approach and more cost-effective method of monitoring. A number of epigenetic changes have been described for many cancer sites, including the urinary bladder. In this review, we discuss the use of epigenetics in bladder cancer and the potential diagnostic and therapeutic applications. MATERIALS AND METHODS: A comprehensive search of the English medical literature was conducted in PubMed using the terms microRNA regulation, DNA methylation, histone modification and bladder cancer. RESULTS: The most important epigenetic changes include DNA methylation, histone modification and microRNA regulation. Both DNA hypomethylation and hypermethylation have been associated with higher rate of cancer. The association of epigenetic changes with bladder cancer has led to the research of its diagnostic and prognostic implications as well as to the development of novel drugs to target these changes with the aim of achieving a survival benefit. CONCLUSIONS: Recently, epigenetics has been shown to play a much greater role than previously anticipated in the initiation and propagation of many tumors. The use of epigenetics for the diagnosis and treatment of bladder cancer is an evolving and promising field. The possibility of reversing epigenetic changes may facilitate additional cancer treatment options in the future.

The role of epigenetics in kidney malignancies.

INTRODUCTION: Renal cell carcinomas (RCC) are collectively the third most common type of genitourinary neoplasms, surpassed only by prostate and bladder cancer. Cure rates for renal cell carcinoma are related to tumor grade and stage; therefore, diagnostic methods for early detection and new therapeutic modalities are of paramount importance. Epigenetics can be defined as inherited modifications in gene expression that are not encoded in the DNA sequence itself. Epigenetics may play an important role in the pursuit of early diagnosis, accurate prognostication and identification of new therapeutic targets. MATERIAL AND METHODS: We used PubMed to conduct a comprehensive search of the English medical literature using search terms including epigenetics, DNA methylation, histone modification, microRNA regulation (miRNA) and RCC. In this review, we discuss the potential application of epigenetics in the diagnosis, prognosis and treatment of kidney cancer. RESULTS: During the last decade, many different types of epigenetic alterations of DNA have been found to be associated with malignant renal tumors. This has led to the research of the diagnostic and prognostic implications of these changes in renal malignancies as well as to the development of novel drugs to target these changes, with the aim of achieving a survival benefit. CONCLUSIONS: Epigenetics has become a promising field in cancer research. The potential to achieve early detection and accurate prognostication in kidney cancer might be feasible through the application of epigenetics. The possibility to reverse these epigenetic changes with new therapeutic agents motivates researchers to continue pursuing better treatment options for kidney cancer and other malignancies.

Utility of 18F-FDG PET in evaluating cancers of lung.

PET has seen rapid progression in recent years, with applications in oncology leading the way. The glucose analog (18)F-FDG is the most commonly used PET radiopharmaceutical and has been shown to accumulate avidly in several different neoplasms, including cancers of the lung. The following discussion will review the physiologic basis for the uptake of (18)F-FDG in lung neoplasms and demonstrate the utility of (18)F-FDG PET in lung cancer. A brief review of other PET radiopharmaceuticals in lung cancer imaging, and dual-modality PET/CT scanners, will be presented. Upon completion of this article, the reader should be able to describe the pharmacokinetics of (18)F-FDG and discuss the efficacy of (18)F-FDG PET scans in the evaluation of solitary pulmonary nodules, disease staging, and monitoring response to therapy. Additionally, the reader should be able to compare (18)F-FDG PET with conventional anatomic imaging and describe some of the technical challenges of PET/CT fusion imaging.

Characterization of (123)I-iodo-alpha-methyltyrosine transport in rat lymphoma cells.

(123)I-Iodo-alpha-methyltyrosine (IMT) transport into lymphomas has not been fully characterized. In rat Nb2-11C and Nb2-Sp lymphoma cell lines, linear uptake of (123)I-IMT occurred rapidly within 5-10 min. Eadie-Hoftee plots of (123)I-IMT uptake gave apparent Km's of 8.34+/-1.17 and 9.64+/-1.05 microM for Nb2-11C and Nb2-Sp cells, respectively, and involved the L and B(0,+) systems. In lymphoma-bearing rats, injected (123)I-IMT accumulated rapidly in the primary tumors but gave a low tumor-to-background ratio of 2:1. (123)I-IMT was transported rapidly into lymphoma cells both in vitro and in vivo, but low target-to-nontarget ratio may not make (123)I-IMT practical for scanning in vivo.