Esophageal tuberculosis as a differential diagnosis of esophageal cancer.

The case of a patient in the eighth decade of life who begins with dysphagia and progressive weight loss is presented, who underwent contrast-enhanced tomography where a tumor was observed in the esophagus, endoscopy with biopsy and a report of esophageal tuberculosis.

Icteric syndrome secondary to polycystic liver disease.

We present the case of a male patient in the sixth decade of life who attended due to the presence of progressive increase in abdominal circumference, accompanied by early satiety, to which generalized jaundice was later added, finding Gigot III polycystic liver disease by imaging methods.

Lymphocytic colitis with macroscopic findings.

The clinical case of a patient in the fifth decade of life with a diagnosis of lymphocytic colitis is presented, who comes for chronic diarrhea, which receives treatment with Budesonide with partial response.

Predictors of exacerbation risk and response to budesonide in patients with chronic obstructive pulmonary disease: a post-hoc analysis of three randomised trials.

BACKGROUND: The peripheral blood eosinophil count might help identify those patients with chronic obstructive pulmonary disease (COPD) who will experience fewer exacerbations when taking inhaled corticosteroids (ICS). Previous post-hoc analyses have proposed eosinophil cutoffs that are both arbitrary and limited in evaluating complex interactions of treatment response. We modelled eosinophil count as a continuous variable to determine the characteristics that determine both exacerbation risk and clinical response to ICS in patients with COPD. METHODS: We analysed data from three AstraZeneca randomised controlled trials of budesonide-formoterol in patients with COPD with a history of exacerbations and available blood eosinophil counts. Patients with any history of asthma were excluded. Negative binomial regression analysis was done using splines for modelling of continuous variables to study the primary outcome of annual exacerbation rate adjusted for exposure time and study design. The trials are registered with ClinicalTrials.gov, NCT00206167, NCT00206154, and NCT00419744. FINDINGS: 4528 patients were studied. A non-linear increase in exacerbations occurred with increasing eosinophil count in patients who received formoterol alone. At eosinophil counts of 0·10 × 109 cells per L or more, a significant treatment effect was recorded for exacerbation reduction with budesonide-formoterol compared with formoterol alone (rate ratio 0·75, 95% CI 0·57-0·99; pinteraction=0·015). Interactions were observed between eosinophil count and the treatment effects of budesonide-formoterol over formoterol on St George's Respiratory Questionnaire (pinteraction=0·0043) and pre-bronchodilator FEV1 (linear effect p<0·0001, pinteraction=0·067). Only eosinophil count and smoking history were independent predictors of response to budesonide-formoterol in reducing exacerbations (eosinophil count, pinteraction=0·013; smoking history, pinteraction=0·015). INTERPRETATION: In patients with COPD treated with formoterol, blood eosinophil count predicts exacerbation risk and the clinical response to ICS. FUNDING: AstraZeneca.

The EORTC tables overestimate the risk of recurrence and progression in patients with non-muscle-invasive bladder cancer treated with bacillus Calmette-Guérin: external validation of the EORTC risk tables.

BACKGROUND: European Organization for Research and Treatment of Cancer (EORTC) risk tables only included 171 patients treated with bacillus Calmette-Guérin (BCG) for non-muscle-invasive bladder cancer (NMIBC). OBJECTIVE: To evaluate the external validity of the EORTC tables in patients with NMIBC treated with BCG over 5-6 mo. DESIGN, SETTING, AND PARTICIPANTS: Data on 1062 patients treated with BCG were analyzed. MEASUREMENTS: Discrimination was assessed using the concordance index (c-index) and the prognostic separation index (PSEP). For calibration, probabilities of recurrence and progression obtained with the EORTC risk tables in our series were compared with those reported by the EORTC. RESULTS AND LIMITATIONS: With respect to the discriminative ability of the EORTC model, c-index was similar to those reported in the EORTC series for recurrence. However, c-indices for progression in our series were lower than c-indices reported by Sylvester et al. [1]. Although PSEP in our series was lower than in the EORTC series for recurrence at 1 yr, similar results were found at 5 yr. Regarding progression, PSEP in our series was lower than in the EORTC series. Whilst a successful stratification of recurrence and progression probability at 1 and 5 yr was achieved using the EORTC tables in our series, model calibration showed lower risks of recurrence than those reported by Sylvester et al. [1] in all groups. For progression, lower risks were found in higher-risk groups. There are some limitations in the present study. A different distribution of patients was found, with higher proportions of primary grade 3 T1 tumors and tumors in situ than in the EORTC series. An additional limitation is that prior recurrence of the EORTC table was not included in our parameters. Consequently, two separate analyses were performed for recurrence. CONCLUSIONS: The EORTC model successfully stratified recurrence and progression risks in our cohort. However, the discriminative ability of the EORTC tables decreased in our patients for progression. Moreover, these tables overestimated risks of recurrence and progression after BCG therapy.

Ureteral double-J wire stent effectiveness after endopyelotomy: an animal model study.

OBJECTIVES: The aim of this experimental study was to assess the possibility of decreasing the size of the ureteral stents used after an endopyelotomy. To this end, an experimental study was performed which compared a ureteral double-J wire stent versus a standard 7F ureteral stent after endopyelotomy. METHODS: Twenty healthy female pigs were randomly divided into 2 groups: group I (double pigtail ureteral stent 7F) and group II (lumenless ureteral double-J wire stent, Zebrastent™, 0.035 inches in diameter). Percutaneous, endoluminal ultrasonographic and fluoroscopic studies were analyzed during the 3 different phases of the study. The first phase included premodel documentation of normal urinary tracts and laparoscopic ureteropelvic junction (UPJ) obstruction induction. During the second phase, 6 weeks later, diagnosis and endopyelotomy were carried out. Sixteen weeks after the obstruction treatment, follow-up imaging studies and postmortem evaluations of all animals were performed. RESULTS: After the sonographic and fluoroscopic assessments, we determined the success rate for each group: 80% for group I and 90% for group II. No significant statistical differences were evident in the evolution of the diameter of the UPJ between groups. Better healing of the UPJ and a lower level of retroperitoneal repercussions were seen in group II. CONCLUSIONS: The ureteral double-J wire stent (Zebrastent) has been shown to be highly effective after endopyelotomy. This means that it is possible to reduce the size of ureteral stents after endopyelotomy with the advantages that this entails. Double-J ureteral stents probably act as a scaffold rather than a mold.

Predicting nonmuscle invasive bladder cancer recurrence and progression in patients treated with bacillus Calmette-Guerin: the CUETO scoring model.

PURPOSE: Bacillus Calmette-Guerin is the most effective therapy for nonmuscle invasive bladder cancer. Recently to calculate the risks of recurrence and progression based on data from 7 European Organisation for Research and Treatment of Cancer trials a scoring system was reported. However, in that series only 171 patients were treated with bacillus Calmette-Guerin. We developed a risk stratification model to provide accurate estimates of recurrence and progression probability after bacillus Calmette-Guerin. MATERIALS AND METHODS: Data were analyzed on 1,062 patients treated with bacillus Calmette-Guerin and included in 4 Spanish Urological Club for Oncological Treatment trials. Stepwise multivariate Cox models were used to determine the effect of prognostic factors. In each patient the weight of all factors was summed to a total score. Patients were then divided into groups, and cumulative recurrence and progression rates were calculated. RESULTS: A scoring system was calculated with a score of 0 to 16 for recurrence and 0 to 14 for progression. Patients were categorized into 4 groups by score, and recurrence and progression probabilities were calculated in each group. For recurrence the variables were gender, age, grade, tumor status, multiplicity and associated Tis. For progression the variables were age, grade, tumor status, T category, multiplicity and associated Tis. For recurrence calculated risks using Spanish Urological Club for Oncological Treatment tables were lower than those obtained with Sylvester tables. For progression probabilities were lower in our model only in patients with high risk tumors. CONCLUSIONS: We propose a scoring model to stratify the risk of recurrence and progression in patients treated with bacillus Calmette-Guerin.

Endourologic techniques for ureteropelvic junction obstruction therapy. Comparative animal study.

PURPOSE: The aim of this work is to compare 3 endourologic techniques for treating a ureteropelvic junction (UPJ) obstruction. To accomplish this, we performed a study in a porcine animal specimen, in which we compared laparoscopic pyeloplasty that emerges as the future gold standard technique, with 2 endopyelotomy techniques. MATERIAL AND METHODS: Twenty-four healthy large white female pigs were randomly divided in 3 groups-group I (laparoscopic pyeloplasty), group II (endopyelotomy-Acucise, Applied Medical, Rancho Margarita, CA), and group III (endoballoon rupture endopyelotomy). Percutaneous and endoluminal ultrasonographic and fluoroscopic studies were analyzed during the different phases of the study. The study was divided in 3 phases. First one included premodel documentation of normal urinary tract and laparoscopic UPJ obstruction induction. During second phase at 6 weeks later, diagnosis and endourologic treatment were carried out. Fifteen weeks after obstruction treatment, follow-up imaging studies and postmortem evaluation of all animals were performed. RESULTS: After the sonographic and fluoroscopic assessment, we determined the percentage of success rate for each technique-with an 87.5% for groups I and II and 75% for group III. Significant statistical differences were found between the 2 pyelotomy groups and the pyeloplasty group regarding the duration of the intervention. Significant statistical differences are evident in the evolution of the UPJ's diameter between groups I and III. CONCLUSIONS: Laparoscopic pyeloplasty is the technique that produces fewer side effects in the reconstructed area, as well as a wider dilation of the UPJ. Nevertheless, as we show in this study, we found similar results between endopyelotomy in selected patients than pyeloplasty, and it is simpler and less invasive than the latter.

Reliability and validity of endoluminal sonography in a porcine model of ureteropelvic junction obstruction.

PURPOSE: The objective of this study was to evaluate the usefulness and reliability of endoluminal ultrasonography in ureteropelvic junction (UPJ) obstruction and to describe the changes in sonographic appearance that take place during obstruction and after treatment. MATERIALS AND METHODS: Twelve large healthy white female pigs were randomly divided into two groups: Group 1 (laparoscopic pyeloplasty) and group 2 (cutting balloon endopyelotomy). Percutaneous and endoluminal ultrasonographic and fluoroscopic studies were analyzed during the three phases of the study. The first phase included premodel documentation of a normal urinary tract and laparoscopic UPJ obstruction. During the second phase 6 weeks later, diagnosis and endourologic treatment were performed. Fifteen weeks after obstruction management, follow-up imaging studies and postmortem evaluation of all animals were performed. RESULTS: At the end of the study, group 1 had a lesser degree of fibrosis in the muscle-adventitia layers and periureteral repercussion, as well as a better peristaltic recovery. The animal study shows a positive correlation among the results of the pathologic and the endoluminal ultrasonographic studies in UPJ obstruction. CONCLUSIONS: Endoluminal ultrasonography provides excellent information regarding ureteral and periureteral anatomy. Among the two techniques evaluated in the study, laparoscopic pyeloplasty caused the lesser reaction at the reconstructed area. Fibrous replacement at the muscle-adventitia layers and periureteral area may be useful as indicators of the better therapeutic technique as well as for the assessment of post-therapeutic ureteral evolution and recurrences.

Prognostic factors in patients with non-muscle-invasive bladder cancer treated with bacillus Calmette-Guérin: multivariate analysis of data from four randomized CUETO trials.

OBJECTIVES: To evaluate the prognostic factors of recurrence and progression after intravesical adjuvant bacillus Calmette-Guérin (BCG) immunotherapy in patients with non-muscle-invasive bladder tumors. METHODS: From February 1990 to May 1999, the Spanish Club Urológico Español de Tratamiento Oncológico (CUETO) group has performed four randomized phase 3 studies comparing different intravesical treatments in patients with noninvasive bladder cancer. Data from 1062 evaluable patients treated only with BCG were analyzed. Most patients received BCG once weekly for 6 consecutive weeks and a short-term BCG maintenance (once every 2 wk 6 times more). Associated tumor in situ (TIS) was found in 7.5% (n=80) of cases. There were 22.1% (n=235) patients with T1G3 tumors, 22.9% of whom (n=54) were associated with TIS. Stepwise multivariate Cox regression models with stratification by study and dose were used to assess the independent effect of predictive factors and hazard ratios (HRs) were estimated from the Cox model. RESULTS: Multivariate analysis demonstrated that female gender (HR=1.71) compared to male gender, recurrent tumors (HR=1.9) compared to primary tumors, multiplicity, and presence of associated TIS (HR=1.54) increased the risk of recurrence. Recurrent tumors (HR=1.62) compared to primary tumors, high-grade tumors (HR=5.64) compared to G1 tumors, T1 tumors (HR=2.15) compared to Ta tumors, and recurrence at 3-mo cystoscopy (HR=4.6) increased the risk of progression. CONCLUSION: Significant independent predictors for recurrence were female gender, history of recurrence, multiplicity, and presence of associated TIS. Age, history of recurrence, high grade, T1 stage, and recurrence at first cystoscopy were independent predictors of progression by multivariate Cox analysis.

A multicentre, randomised prospective trial comparing three intravesical adjuvant therapies for intermediate-risk superficial bladder cancer: low-dose bacillus Calmette-Guerin (27 mg) versus very low-dose bacillus Calmette-Guerin (13.5 mg) versus mitomycin C.

OBJECTIVE: The primary aim was to search for lower doses of Bacillus Calmette-Guerin (BCG) that are effective and have lower toxicity. METHODS: A low dose of BCG 27 mg was compared with BCG 13.5mg, using mitomycin C (MMC) 30 mg as the third arm of comparison. A total of 430 patients with intermediate-risk superficial bladder cancer were randomised into three groups. Instillations were repeated once a week for 6 wk followed by another six instillations given once every 2 wk during 12 wk. RESULTS: There was a significantly longer disease-free interval for BCG 27 mg versus MMC 30 mg (p=0.006). There were no statistically significant differences between BCG 27 mg and BCG 13.5mg (p=0.165) or between BCG 13.5mg and MMC 30 mg (p=0.183). Cox proportional hazards regression showed that disease-free interval in the multivariate analysis was significantly better for primary disease and treatment with BCG 27 mg. There were no significant differences among the three groups with regards to time to progression and cancer-specific survival time. Local and systemic toxicity were higher in both BCG treatment groups. CONCLUSIONS: One third of the standard dose, BCG 27 mg, seems to be the minimum effective dose as adjuvant treatment for intermediate-risk superficial bladder cancer, being more effective than MMC 30 mg. One sixth of the standard dose, BCG 13.5mg, has the same efficacy as MMC 30 mg but it is more toxic.

Evaluation of the duration of ureteral stenting following endopyelotomy: Animal study.

BACKGROUND: The purpose of the present paper was to evaluate whether it is possible to reduce the duration of ureteral stenting following endopyelotomy, and thus reduce side-effects. METHODS: Seventeen pigs were used. They were distributed at random into three groups. The study was divided as follows: phase I included baseline study of the urinary system and the creation of a ureteropelvic junction obstruction (UPJO) model. Phase II, 1 month later, consisted of diagnosing UPJO, Acucise endopyelotomy of the same, and the placement of a ureteral stent. Ureteral stents were left in situ for 1 week in group I, for 3 weeks in group II and 6 weeks in group III. Phase III, 3 months after treatment, consisted of follow up and post-mortem studies of the animals. The following procedures were carried out during each phase: ureteropelvic junction (UPJ) diameter measurement, ultrasound percutaneous and endoluminal studies, urine culture and determination of blood urea and creatinine levels. RESULTS: On removal of the stent, the presence of urinoma was observed in two animals in group I. There were statistically significant differences between group I and III with regard to evolution of the internal diameter of the UPJ. However, the least severe histological lesion at the UPJ level was found in group II. CONCLUSIONS: Ureteral stent placement for 1 week is insufficient in order to assure correct healing and evolution of the UPJ following endopyelotomy. Stenting for 3 weeks is effective, and it is not necessary to extend stenting time to 6 weeks. Endoluminal ultrasound is of great use in determining the effects of endourological techniques in the ureter and the retroperitoneal space. It is also useful for deciding which therapeutic technique to use, and for inserting the Acucise in order to prevent iatrogenic problems.

Epidermal naevus syndrome (Solomon's syndrome) associated with bladder cancer in a 20-year-old female.

Epidermal naevus syndrome was first described by Solomon et al. in 1968, based on a study of 12 patients. Herein we report the case of a 20-year-old female diagnosed with epidermal naevus syndrome at the age of 3 years. Subsequently she experienced several different symptoms and at the last exploration a suspicious lesion was found in her bladder. The definitive pathology diagnosis was transitional cell carcinoma of the bladder, which is extremely rare in patients aged <21 years. It seems that this neoplastic lesion was directly related to the essential pathology of the patient, namely epidermal naevus syndrome.