Testicular "tumor" of the adrenogenital syndrome: a case report of an unusual association with myelolipoma and seminoma in cryptorchidism.

BACKGROUND: Males with congenital adrenal hyperplasia may develop bilateral testicular masses in early adult life. These are not malignant and generally regress with corticosteroid therapy. The authors report a case occurring in a 44-year-old man with associated seminoma and myelolipoma in an undescended testis. METHODS: The testicular tumors were analyzed by histologic, flow cytometric, and ultrastructural techniques. RESULTS: The tumors in both testes were comprised of polygonal cells with abundant granular eosinophilic cytoplasm, occasionally with brown (lipochrome) pigment and round nuclei of various sizes with prominent nucleoli. These cells were grouped into nodules by dense and sometimes thick fibrous trabeculae in the right testis. The areas corresponding to the fibrous trabeculae in the left (intraabdominal) testis were replaced by mixture of hematopoietic (myeloid) and fatty tissue in various proportions characteristic of myelolipoma. The left testis also had a well demarcated tumor that was diagnostic of seminoma. Electron microscopy demonstrated abundant smooth endoplasmic reticulum, a moderate number of mitochondria with tubulovesicular cristae, lipid droplets, and lipofuscin granules in the polygonal cells. No Reinke's crystals were observed. The patient received corticosteroids for his adrenocorticoid deficiency and also underwent external beam irradiation to the retroperitoneum for seminoma. CONCLUSIONS: This case illustrates an unusual presentation of a testicular tumor in a patient with the adrenogenital syndrome as well as with myelolipoma and seminoma in a cryptorchid testis. The possibility of an associated neoplasm that could be potentially fatal should be considered whenever a testicular tumor of the adrenogenital syndrome continues to grow despite adequate hormonal treatment.

Value of prostatic cancer screening in patients treated for benign prostatic hyperplasia with medical or minimally invasive modalities.

OBJECTIVE: To assess the likelihood of overlooking the diagnosis of prostate cancer (PCA), using current screening methods, in patients treated for benign prostatic hyperplasia (BPH) with medical or minimally invasive treatment modalities, which do not produce tissue specimens for histologic review. To appraise this, we examined the impact of the preoperative use of prostatic specific antigen (PSA) in combination with transrectal ultrasound (TRUS) and systematic sextant prostate needle biopsy (PNbx) on the subsequent incidence of stage A PCA in patients undergoing transurethral resection of the prostate (TURP). METHODS/RESULTS: After excluding all patients found to have PCA during pretreatment screening, 485 patients who underwent TURP for presumed BPH from 1976 to 1994, were reviewed. From 1976 to 1989, PSA was not used for pretreatment screening, and stage A PCA was diagnosed in 11.4% of 317 patients. In 1990 and 1991, pretreatment screening included PNbx obtained under ultrasound guidance for PSA > or = 15.0 ng/ml. Stage A PCA was diagnosed in 14.2% of 63 patients. From 1992 to 1994, pretreatment screening included systematic sextant PNbx performed for PSA > 4.0 ng/ml, and stage A PCA was diagnosed in 2.8% of 105 patients. The difference in incidence of stage A PCA between the first two groups and group three was significant (p = 0.021); so is the difference in incidence of stage A2 (p = 0.037). For stage A1, the difference did not reach statistical significance (p = 0.089). CONCLUSION: Our findings suggest that systematic sextant PNbx for PSA > 4.0 ng/ml significantly reduces the risk of overlooking prostate cancer in patients undergoing treatment of BPH with modalities that do not provide tissue specimens.

Antegrade balloon dilation of postoperative ureterovesical junction obstruction in children.

Obstruction of the ureterovesical junction is an uncommon but well-recognized complication of ureteral reimplantation that traditionally has been treated by surgical correction [1, 5-9]. We report our experience with antegrade balloon dilation (ABD) of these strictures in two children. Obstruction was confirmed by diuretic renogram and pressure perfusion studies prior to ABD. Clinical follow-up was done at 3 months and 14 months, and ultrasonographic studies revealed resolution of the hydronephrosis. In addition, diuretic renograms showed complete washout of radiotracer. Morbidity was limited to episodes of pyelonephritis that readily responded to medical management. ABD of ureteral strictures is a relatively simple procedure with a potential for a high success rate and low morbidity. This modality should be considered as the first line of treatment in patients with distal ureteral obstruction after reimplantation.

Are we overlooking stage a prostate cancer in patients treated for benign prostatic hyperplasia with medical or minimally invasive modalities?

Our objective was to assess the likelihood of overlooking the diagnosis of prostate cancer (PCA), using current screening methods, in patients treated for benign prostatic hyperplasia (BPH) with medical or minimally invasive treatment modalities, which do not produce tissue specimens for histologic review. To appraise this, we examined the impact of the preoperative use of prostatic specific antigen (PSA) in combination with transrectal ultrasound (TRUS) and systematic sextant prostate needle biopsy (PNbx) on the subsequent incidence of stage A PCA in patients undergoing transurethral resection of the prostate (TURP). After excluding all patients found to have PCA during pretreatment screening, 485 patients who underwent TURP for presumed BPH from 1976 to 1994 were reviewed. From 1976 to 1989, PSA was not used for pretreatment screening, and stage A PCA was diagnosed in 11.4% of 317 patients. In 1990 and 1991, pretreatment screening included PNbx obtained under ultrasound guidance for PSA of 15.0 ng/ml or greater. Stage A PCA was diagnosed in 14.2% of 63 patients. From 1992 to 1994, pretreatment screening included systematic sextant PNbx performed for PSA greater than 4.0 ng/ml, and stage A PCA was diagnosed in 2.8% of 105 patients. The difference in incidence of stage A PCA between the first two groups and group three was significant (p = 0.021), as it was the difference in incidence of stage A(2) (P = 0.037). For stage A(1), the difference did not reach statistical significance (p = 0.089). Our findings suggest that systematic sextant PNbx for PSA greater than 4.0 ng/ml significantly reduces the risk of overlooking prostate cancer in patients undergoing treatment of BPH with modalities that do not provide tissue specimens.

Failure of the polymerase chain reaction (PCR) to detect human papilloma virus (HPV) in transitional cell carcinoma of the bladder.

In contrast to cervical and penile carcinoma, in situ hybridization techniques have not been able to demonstrate an association of HPV with transitional cell carcinoma (TCC) of the bladder. The introduction of the polymerase chain reaction (PCR) in the mid 1980s has significantly increased the ability to detect small quantities of viral DNA over conventional methods. Thus, we designed a study to determine if the PCR technique was able to demonstrate the presence of HPV DNA in TCC specimens. The study involved both consensus primers directed toward the E1 and L1 open reading frames of the HPV viral DNA, specific for HPV 6, 11, 16, 18, 31, 33. Thirty-three TCC specimens were studied (Fresh: 8, paraffin embedded: 25). Seven were Grade I, nine Grade II, seventeen Grade III; thirteen were superficial (Stages 0 and A) and twenty were invasive or metastatic (Stages B or Higher). None of the patients had known evidence of clinical HPV infection. In each experiment, the CaSki cell line was used for a positive control. In addition, the results of the PCR reactions were confirmed by Southern blot hybridization. Neither the PCR by direct ethidium bromide viewing, nor the Southern blot technique detected HPV DNA in any of the TCC specimens. This was in contrast to our controls, which were positive by both techniques. Although it is possible that there is a link between HPV and TCC, our results suggest that there is no such association among the HPV types tested.

Nondilated obstructive uropathy and renal failure as a result of carcinoma of the intrapelvic area.

Renal failure secondary to obstruction of the urinary tract can sometimes present with only minimal or even no dilatation of the proximal part of the urinary tract; this is especially true when a history of malignancy within the pelvic area exists. Approximately 4 per cent of the patients who present with renal failure because of obstructive uropathy do so with minimal or no dilatation. Of these, approximately 60 per cent are associated with an intrapelvic malignancy. When a patient with renal failure presents with the associated findings of an intrapelvic or retroperitoneal tumor, it is imperative that obstructive uropathy be ruled out, even in the absence of dilatation.