Perineal schwannoma: an unusual tumor and clinical presentation - first case with erectile dysfunction associated with this neoplasm.

INTRODUCTION: Perineal schwannomas (PS) are very rare benign tumors with few cases reported in literature and none of these reports erectile dysfunction among clinical presentations. CASE DESCRIPTION: We report a case of PS with unusual clinical presentation showing erectile dysfunction associated with perineal pain and discomfort during defecation, and the postoperative residual pain and erectile dysfunction treatment. CONCLUSIONS: On the basis of a literature review of all cases reported and on our case reported, we have delineated a clinical, diagnostic, and therapeutic profile of PS, summarized in a useful table.

A proposed score for assessing progression in pT1 high-grade urothelial carcinoma of the bladder.

We tested a selected series of patients with single urothelial high-grade pT1 stage (pT1 HG) or urothelial carcinoma in situ (CIS) with a set of immunohistochemical markers to elaborate a risk score for progression. We retrospectively reviewed all first diagnoses of single, <3 cm, urothelial papillary carcinoma pT1 HG or isolated CIS between 2006 and 2009. Galectin-3, CD44, E-cadherin, CD138, p16, survivin, HYAL-1, and topoisomerase-II α were used. A grading score 0 or 1 for each immunohistochemical staining was assigned to obtain a total score for assessing the progression. The median "progression score" was selected as cutoff value for statistical analysis. Overall, 23 patients (19 pT1 HG and 4 CIS) were included in the study. After a median follow-up of 21 months (range, 12 to 34 mo), 9 patients (39.1%) showed disease recurrence whereas 4 patients (17.4%) showed tumor progression. Topoisomerase-II α, p16, survivin, galectin-3, and CD138 were significantly associated with progression. Progression score ranged from 0 (best prognosis) to 7 (worst prognosis). Using a score ≥5 as a threshold, specificity was 78.9%, sensitivity 100%, positive predictive value 50%, and negative predictive value 100%. ROC area (a 95% confidence interval, 0.807-1.000; P<0.001). This immunohistochemistry-based progression score using a threshold ≥5, might help the clinician to focus on patients with HG pT1 or extended CIS at high risk for disease progression. These patients might benefit from a more intensive follow-up program or early cystectomy.

The role of free to total PSA ratio in prediction of extracapsular tumor extension and biochemical recurrence after radical prostatectomy in patients with PSA between 4 and 10 ng/ml.

OBJECTIVES: The prognostic value of free to total PSA ratio (F/T PSA) in patients eligible for radical prostatectomy (RP) is controversial. The aim of the present study was to evaluate correlation of F/T PSA with tumor extracapsular extension (ECE) and biochemical recurrence (BR) at long-term follow-up. PATIENT AND METHODS: Clinical and pathological data were prospectively gathered from 200 patients treated with RP for clinically localized prostate cancer (PCa) and PSA between 4 and 10 ng/mL. Correlations of preoperative variables including F/T PSA with ECE and BR were evaluated with uni- and multivariate analysis. Adjunctive analyses evaluated the association of PSA F/T with other pathological results. The relationship between preoperative F/T PSA and BR was also assessed with Kaplan­Meier survival analysis. RESULTS: Lower F/T PSA was significantly correlated with ECE (p = 0.0063), higher GS (p = 0.0054), and seminal vesicles involvement (p = 0.0047). The F/T PSA value of 14% provided the greatest discrimination in predicting ECE. At multivariate analysis, F/T PSA did not achieve the statistical significance for predicting ECE independently. At a mean (median, range) follow-up of 52 (48, 14­116) months, preoperative F/T PSA resulted significantly correlated with BR (p = 0.001). At the Kaplan­Meier survival analysis, the 5-year BR free survival rate resulted 89.3 and 68.9% in the group with F/T PSA >14 and ≤14 ng/mL, respectively (log rank p = 0.0022). At Cox proportional hazard model, only ECE resulted an independent predictor of BR (R = 2.646, p = 0.037). CONCLUSION: In patients with clinically localized PCa and PSA 4­10 ng/ml, lower F/T PSA was significantly associated with ECE, other adverse pathologic features, and with BR at the long-term follow-up, but only ECE resulted an independent predictor of BR in our series.

Prognostic role of perineural invasion in 239 consecutive patients with pathologically organ-confined prostate cancer.

OBJECTIVE: The aim of our study was to analyze the role of perineural invasion (PNI) as a predictive parameter of outcome after radical prostatectomy (RRP) in pathologically organ-confined prostate cancer (PCa) and to assess its possible correlation with other well-known prognostic features. PATIENTS AND METHODS: At our institution between January 2000 and December 2007, we prospectively collected data from 251 consecutive patients with pathologically localized PCa after antegrade RRP. In our analysis 239 patients were included. PNI was defined as adenocarcinoma within the perineural space adjacent to a nerve. We evaluated the biochemical progression-free survival rate using the Kaplan-Meier method to establish the correlation between PNI and prognosis, the log-rank test to verify the statistical significance, and χ(2) test to investigate the correlation between PNI and other clinicopathological parameters. RESULTS: We found intraprostatic PNI in 157 patients (65.7%). The PNI rate was 73% (149/204) in pT2b-c vs. 26% (8/35) in pT2a surgical specimens (p < 0.001), and it was 78.5% (73/93) in patients with a Gleason score of 7-10 vs. 57% (84/146) in a Gleason score of 2-6 (p < 0.01). The mean follow-up was 65.4 (median 62, range 24-118) months. Overall, 11/239 (4.6%) patients presented biochemical recurrence after surgery and 7 (63.6%) of these patients showed PNI, but this was not statistically higher than in patients free from progression (150/228, 65.7%). The actuarial biochemical progression-free survival rate for all patients was 96.9 and 93.5% at 60 and 84 months, respectively, and the stratification based on the presence or absence of PNI did not allow us to identify different prognostic groups. CONCLUSIONS: Perineural infiltration frequently takes part in the pathway of extraprostatic extension. In our series, patients with pathological T2 stages and PNI were found to present a higher pT2 stage and Gleason score, even though our early biochemical-free outcome was not significantly higher than in patients without PNI.

Review of the current status of tumor enucleation for renal cell carcinoma.

Tumor enucleation consists of excising the tumor by blunt dissection following the natural cleavage plane between the peritumoral pseudocapsule and the renal parenchyma without removing a visible rim of healthy renal tissue. In the very recent years, the urological current opinion have changed from a wide skepticism against tumor enucleation to a wider level of acceptance based on the lack of correlation between the width of the resection margin and the risk of disease progression/local recurrence and on larger retrospective series on tumor enucleation with longer follow up. The aim of the present review is to report the technique of tumor enucleation, discuss some technical aspects that can vary between centers and to summarize the oncological and surgical results of this technique for the conservative treatment of RCC in the last 10 years; finally, to briefly present the pathological findings on pseudocapsule and surgical margins prospectively evaluated after tumor enucleation.

Histopathologic analysis of peritumoral pseudocapsule and surgical margin status after tumor enucleation for renal cell carcinoma.

BACKGROUND: The oncologic safety of blunt tumor enucleation (TE) of renal cell carcinoma (RCC) depends on the presence of a continuous pseudocapsule (PS) around the tumor and on the possibility of obtaining negative surgical margins (SMs). OBJECTIVE: To investigate the PS and SMs after TE to define the real need to take a rim of healthy parenchyma around the tumor to avoid the risk of positive SMs. The risk of PS invasion related to other clinical and pathologic variables was also evaluated. DESIGN, SETTING, AND PARTICIPANTS: Between September 2006 and December 2007, data were gathered prospectively from 187 consecutive patients who had kidney surgery. Overall, 90 consecutive patients who had TE for RCC were eligible for the study. All specimens were evaluated using an image analyzer by a dedicated uropathologist. INTERVENTION: TE was done by blunt dissection using the natural cleavage plane between the tumor and the normal parenchyma. MEASUREMENTS: PS, SM, and routinely available clinical and pathologic variables were recorded. RESULTS AND LIMITATIONS: In 60 RCC tumors (67%) the PS was intact and free from invasion (PS-) while in 30 (33%) there were signs of penetration within its layers, with or without invasion beyond it. Indeed, 26.6% had PS that had been penetrated on the parenchymal side and 6.6% had penetration on the perirenal fat tissue side. The odds of having PS penetration increased significantly with an increase in clinical tumor size. PS penetration was also significantly associated with pathologic tumor dimensions and grade. In all cases the SMs were negative after TE. The present patients, followed for >2 yr, will enable us to correlate the risk of local recurrence with PS status. CONCLUSIONS: The risk of PS penetration is associated with clinical and pathologic tumor dimensions and grade. If there is PS invasion into normal parenchyma, the presence of a thin layer of tissue allows for negative SM even if a TE is performed.

Simple enucleation for the treatment of renal angiomyolipoma.

OBJECTIVES: To report on the role of simple enucleation for treating renal angiomyolipoma (AML) in a series of patients treated in our department. PATIENTS AND METHODS: We retrospectively reviewed the data of all 37 patients with a histopathological diagnosis of renal AML who had either radical nephrectomy (three) or nephron-sparing surgery by simple enucleation (34) between January 1986 and December 2005. Indications for intervention included either symptomatic AML or a tumour of >4 cm, regardless to the presence of symptoms or renal masses suspicious of malignancy. The patients' status was evaluated last in October 2006. RESULTS: The mean (sd, median, range) pathological tumour size was 5.2 (3.4, 4.8, 1.5-15) cm; five patients (15%) were affected by tuberous sclerosis. Simple enucleation was successful in all patients but in three (9%) a sharp dissection a few millimetres from the tumour was used during critical steps of the procedure where it seemed difficult to define the right plane of enucleation. Warm ischaemia was used in 79% of patients, with a mean ischaemic time of 11.2 min. Two patients (6%) required renal hypothermia. A simple parenchymal compression was used in five cases (15%). The mean (range) intraoperative blood loss was 170 (70-650) mL. None of the patients had postoperative bleeding requiring re-intervention but one (3%) required two units of blood after surgery. There were no major complications, e.g. prolonged acute tubular necrosis/chronic renal insufficiency and urinary leakage/urinoma, but two patients had urosepsis not associated with perirenal fluid collection and that required targeted antibiotic therapy. At a mean (median, range) follow-up of 56 (50.5, 10-120) months none of the patients had local tumour recurrence. Two patients had a small AML elsewhere in the operated kidney, detected 18 and 36 months after surgery, with a kidney recurrence rate of 6%. CONCLUSIONS: Our data confirm the optimum results of simple enucleation for renal AMLs; this technique provides excellent long-term local control and no patient had urinary leakage/fistula afterward.