Multiparametric magnetic resonance imaging predicts the presence of prostate cancer in patients with negative prostate biopsy.

OBJECTIVE: To assess the ability of multiparametric prostate magnetic resonance imaging (mpMRI) to detect prostate cancer in patients with prior negative transrectal prostate biopsy (TPB). MATERIAL AND METHODS: mpMRI (TSE-T2-w, DWI and DCE sequences) was performed on 1.5T (Magnetom Avanto; Siemens Healthcare Solutions) in 150 patients suspicious of prostate cancer and with negative TPB. European Society of Urogenital Radiology (ESUR) criteria were used (score 1: clinically significant disease is highly unlikely to be present; score 2: clinically significant cancer is unlikely to be present; score 3: clinically significant cancer is equivocal; score 4: clinically significant cancer is likely to be present; score 5: clinically significant cancer is highly likely to be present). PSA measurement (total and free), digital rectal examination (DRE), transrectal ultrasound (TRU) and a second TPB (at least 14 cylinders) were performed in all patients. Variables were submitted for independent blind analysis. The accuracy of each test was measured. Stepwise selection model for prediction of prostate cancer in second TPB was developed. RESULTS: Mean age was 66.2± 5 years (51-77), mean PSA 11.3± 9.6ng/mL (0.9-75) and mean prostatic volume 82.2±42 (20-250) cc. DRE was suspicious in 11 (7.3%) patients. The mean number of cylinders per patient sampled in second TRB was 17.6±2.7(14-22). Second TRB was positive in 28 patients (18.7%). mpMRI was positive (score 3-5) in 102 (68%), test sensibility was 92.9% and the NPV was 95.8%. The risk of prostate cancer diagnosis in second TPB is modified by: PSA velocity > 0.75 (OR 1.04 [0.99-1.08]; P=0.06), free/total ratio PSA <15% (OR 0.37 [0.13-1.05]; P=0.06), each cc. of prostate volume (OR 0.98 [0.97-1]; P=0.017) and mpMRI 3-5 (OR 7.87 [1.78-34.7]; P=0.006). Multivariate analysis reveals that mpMRI (OR 7.41 [1.65-33.28]; P=0.009) and prostatic volume (OR 0.31 [0.12-0.78]; P=0.01) are independent risk predictors of prostate cancer. CONCLUSIONS: According to ESUR guidelines and in patients with prior negative prostate biopsy, mpMRI is a valuable tool for the prediction of prostate cancer in second TPB. Lower prostate volume, the higher reliability.

Multiparametric magnetic resonance imaging for the assessment of extracapsular invasion and other staging parameters in patients with prostate cancer candidates for radical prostatectomy.

INTRODUCTION: the proper evaluation of the extracapsular extension (ECE), the invasion of seminal vesicles and regional lymph nodes are necessary to plan the treatment of localized prostate cancer. A model that assesses the risk of ECE in the specimen considering the clinical, histological and imaging findings is defined. MATERIAL AND METHODS: prospective study in 85 patients with prostate cancer treated with radical prostatectomy. Prostate biopsy was performed 4 weeks before multiparametric study (mpMRI). mpMRI included T2-weighted endorectal magnetic resonance imaging (T2W-MRI), diffusion-weighted magnetic resonance imaging (DW-MRI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). The apparent diffusion coefficient (ADC) was also measured. A study of consistency (k) was assessed comparing receiver operating characteristic (ROC) curve and area under the curve (AUC), which were obtained in each case (Z). Finally, a regression model was performed to predict ECE. RESULTS: the mean age was 63.7 ± 6.9 years and the mean value of PSA 12.6 ± 13.8. In 31.7% of cases, digital rectal examination was suspicious for malignancy. Prostatectomy specimen showed pT2a in 12 cases (14%), pT2b in 3 (3%), pT2c in 37 (43%), pT3a in 19(22%) and pT3b 14 cases (17%). ECE was evidenced in 33 (39%) of the specimens, seminal vesicle invasion in 14 (16.5%) and pelvic node involvement in 5 patients (6%). The consistency in the evaluation of ECE (image and pathological studies) was .35 for MRI (sensitivity .33, specificity .96) and .62 for mpMRI (sensitivity .58, specificity .98). Mean value of ADC was .76 ± .2 in patients with ECE. This value was not associated with Gleason score (P = .2) or with PSA value (P = .6). AUC value as predictor of ECE was of 65% for MRI, 78% for mpMRI and 50% ADC (Z = .008). Univariate analysis demonstrated that ECE probability increases with each Gleason score point, whilst this probability increases 1.06 times with each PSA point, and decreases .3 times with each point of ADC. Multivariate analysis confirmed that ADC value is a slight protective factor against ECE (OR = .01; CI 95% .002-.14). The consistency in the evaluation of seminal vesicles was .43 for MRI and .67 for mpMRI. AUC was 69% and 82% respectively (Z = .02). The consistency in the evaluation of positive lymph nodes was .4 for MRI and .7 for mpMRI. AUC was 68% and 88% respectively (Z = .36). CONCLUSIONS: multiparametric study allows to carry out a more proper preoperative evaluation of ECE than convectional MRI. The most reliable predictors of ECE are DW-MRI combined with DCE-MRI, ADC coefficient and Gleason score. The superiority of mpMRI is also demonstrated for detection of seminal vesicles invasion, but not for the evaluation of lymph nodes invasion.

Evaluación del riesgo de invasión muscular, afectación perivesical y/o ganglionar mediante resonancia magnética nuclear balanceada con difusión en el paciente candidato a cistectomía radical / Evaluation of Risk of Muscle Invasion, Perivesical and/or Lymph Node Affectation by Diffusion-Weighted Magnetic Nuclear Resonance in the Patient Who is a Candidate for Radical Cystectomy

Introducción: La estadificación preoperatoria del cáncer vesical por métodos de imagen presenta serias limitaciones. Se evalúa la exactitud de la resonancia magnética abdominal balanceada con difusión (MRI-DW) para predecir invasión muscular residual, afectación perivesical y/o ganglionar en el espécimen de cistectomía. Material y métodos: Estudio prospectivo sobre 20 pacientes con cáncer de vejiga músculo-invasivo de alto grado que recibieron RTU vesical en un plazo menor de un mes. Se realizó MRI-DW antes de cistectomía radical y el radiólogo predijo invasión muscular, afectación extravesical y afectación ganglionar de manera ciega al estudio histopatológico. Se analizó sensibilidad (S), especificidad (E), valor predictivo positivo (VPP), valor predictivo negativo (VPN) y exactitud (Ex) de la prueba. Se compararon medianas de valor ADC (Mann-Whitney) y se llevó a cabo estudio de curvas ROC para MRI-DW y ADC. Resultados: La distribución por categorías fue: pT0 1(5%), pT1 6(30%), pT2 2 (10%), pT3 8 (40%) y pT4 3 (15%). Existió acuerdo en la asignación T-pT en 17 (85%). En 7 (35%) hubo afectación ganglionar (pN1-2). La consistencia de MRI-DW para afectación muscular fue k = 0,89 (IC 0,67-1; S = 1,0, E = 0,86, VPP = 0,93, VPN = 1,0, Ex = 0,95), para afectación de grasa perivesical k = 0,6 (IC 0,25-0,95; S = 0,8, E = 0,8, VPP = 0,8, VPN = 0,8, Ex = 0,8) y para afectación ganglionar k = 0,89 (IC 0,67-1; S = 0,86, E = 1,0, VPP = 1,0, VPN = 0,93, Ex = 0,95). La media de valor de ADC fue mayor en tumores G2 (OMS 1987) frente a G3 (p = 0,08). La evaluación por imagen de MRI-DW y el valor numérico ADC mostraron áreas bajo la curva equivalentes para afectación muscular (0,93 y 0,9; Z = 0,7), grasa (0,8 y 0,91; Z = 0,31) y ganglionar (0,93 y 0,97; Z = 0,36), respectivamente. Conclusiones: MRI-DW permite una buena evaluación preoperatoria del paciente candidato a cistectomía, especialmente para la predicción de afectación muscular (< pT2 vs ≥ pT2) y/o ganglionar (N0 vs N1-2), ambos puntos clave para elegir la actitud terapéutica después de RTU vesical. Además, el coeficiente ADC predice también el grado de diferenciación tumoral (AU)

Introduction: Preoperative staging of bladder cancer using imaging methods has serious limitations. The accuracy of the abdominal diffusion-weighted magnetic resonance (DW-MRI) to predict residual muscle invasion, perivesical and/or lymph node affectation in the cystectomy specimen is evaluated. Material and methods: A prospective study was performed on 20 patients with high grade muscle invasive bladder cancer who received transurethral resection of the bladder (TURB) in a period of < 1 month. The DW-MRI was performed before the radical cystectomy and the radiologist predicted muscle invasion, extravesical affectation and lymph node affectation, being blind to the histopathological study. Sensitivity (S), specificity (sp), positive predictive value (PPV), negative predictive value (NPV) and accuracy (Ac) of the test were analyzed. The medians of the apparent diffusion coefficient (ADC) value (Mann-Whitney) were compared and the ROC curves study for DW-MRI and ADC was carried out. Results: Distribution by categories was: pT0 1 (5%), pT1 6 (30%), pT2 2 (10%), pT3 8 (40%) and pT4 3(15%). There was agreement in the T-pT assignment in 17 (85%). In 7 (35%) there was lymph node affectation (pN1-2). Consistency of the DW-MRI for muscle affectation was k =0 .89 (CI .67-1; S = 1.0, Sp = ,86, PPV = 0.93, NPV = 1.0, Ac = .95), for perivesical fat affectation k = 0.6 (CI .25-.95; S =0 .8, Sp = 0.8, PPV =0 .8, NPV =0 .8, Ac =0 .8) and for lymph node affectation k = 0.89 (CI .67-1; S = 0.86, Sp = 1.0, PPV = 1.0, NPV =0 .93, Ac =0 .95). Mean value of ADC was greater in G2 tumors (OMS1987) compared to G3 (p =0 .08). Evaluation of DW-MRI imaging and ADC numerical value showed equivalent areas under the curve for muscle (0.93 and 0 .9; Z = .7), fat (0.8 and 0.91; Z = 0.31) and lymph node (0.93 and 0.97; Z = 0.36) affectation, respectively. Conclusions: DW-MRI allows for good pre-operative evaluation of the patient who is a candidate for cystectomy, especially for the prediction of muscle (< pT2 vs ≥ pT2) and/or lymph node (N0 vs N1-2) affectation. Both are key points to choice the therapeutic attitude after the bladder TURB. Furthermore, the ADC coefficient also predicts tumor differentiation grade (AU)

Evaluation of risk of muscle invasion, perivesical and/or lymph node affectation by diffusion-weighted magnetic nuclear resonance in the patient who is a candidate for radical cystectomy.

INTRODUCTION: Preoperative staging of bladder cancer using imaging methods has serious limitations. The accuracy of the abdominal diffusion-weighted magnetic resonance (DW-MRI) to predict residual muscle invasion, perivesical and/or lymph node affectation in the cystectomy specimen is evaluated. MATERIAL AND METHODS: A prospective study was performed on 20 patients with high grade muscle invasive bladder cancer who received transurethral resection of the bladder (TURB) in a period of <1 month. The DW-MRI was performed before the radical cystectomy and the radiologist predicted muscle invasion, extravesical affectation and lymph node affectation, being blind to the histopathological study. Sensitivity (S), specificity (sp), positive predictive value (PPV), negative predictive value (NPV) and accuracy (Ac) of the test were analyzed. The medians of the apparent diffusion coefficient (ADC) value (Mann-Whitney) were compared and the ROC curves study for DW-MRI and ADC was carried out. RESULTS: Distribution by categories was: pT0 1(5%), pT1 6(30%), pT2 2(10%), pT3 8(40%) and pT4 3(15%). There was agreement in the T-pT assignment in 17(85%). In 7(35%) there was lymph node affectation (pN1-2). Consistency of the DW-MRI for muscle affectation was k=.89 (CI .67-1; S=1.0, Sp=,86, PPV=.93, NPV=1.0, Ac=.95), for perivesical fat affectation k=.6 (CI .25-.95; S=.8, Sp=.8, PPV=.8, NPV=.8, Ac=.8) and for lymph node affectation k=.89 (CI .67-1; S=.86, Sp=1.0, PPV=1.0, NPV=.93, Ac=.95). Mean value of ADC was greater in G2 tumors (OMS1987) compared to G3 (p=.08). Evaluation of DW-MRI imaging and ADC numerical value showed equivalent areas under the curve for muscle (.93 and .9; Z=.7), fat (.8 and .91; Z=.31) and lymph node (.93 and .97; Z=.36) affectation, respectively. CONCLUSIONS: DW-MRI allows for good pre-operative evaluation of the patient who is a candidate for cystectomy, especially for the prediction of muscle (

Prescripción de fármacos anticatarrales de uso sistémico a niños de 0-13 años. Un problema no resuelto / Prescription of systemic cold and cough drugs to children 0-13 years old. An unresolved problem

Introducción y objetivos: La infección de las vías respiratorias superiores es el motivo de consulta pediátrica más frecuente, generando un elevado volumen de prescripción de fármacos con desfavorable relación riesgo-beneficio. El objetivo del estudio es describir la prescripción de anticatarrales por vía sistémica a menores de 14 años en Castilla y León y analizar su variabilidad. Población y métodos: Se contabilizaron las prescripciones de los subgrupos R05 (antitusivos y mucolíticos) y R01B (simpaticomiméticos) realizadas a menores de 14 años en el sistema público de salud entre 2005-2010. Se analizaron las prescripciones como tasas crudas y ajustadas por edad, y se realizó un análisis multivariante (regresión de Poisson) de la variabilidad relacionada con el área sanitaria, el ámbito urbano/rural, la edad y el año de prescripción. Resultados: Hubo 806.785 prescripciones de anticatarrales sistémicos realizadas a una población expuesta de 1.580.229 personas-año. Las tasas de prescripción (por 100 personas-año) fueron de 20,7 (antitusivos), 7,0 (simpaticomiméticos) y 23,4 (mucolíticos). Las tasas eran mayores en los niños menores de 4 años. La prescripción máxima de mucolíticos y simpaticomiméticos ocurrió a la edad de 1 año (tasas de 41,9 y 18,7) y la de antitusivos a los 3 años (35,7). El análisis multivariante demostró una mayor prescripción en el medio rural y diferencias notables entre áreas. El número de prescripciones disminuyó entre 2005 y 2010, pero no hubo una tendencia estable en esa reducción. Conclusiones: Entre 2005 y 2010 la prescripción de anticatarrales sistémicos fue alta, alejada de las recomendaciones internacionales de tratamiento y con una marcada variabilidad geográfica(AU)

Introduction and objectives: Upper respiratory tract infections are the most common cause of paediatric consultation, generating a high volume of prescriptions of drugs with unfavourable risk-benefit ratio. The aim of this study is to describe the prescription of systemic cough and cold medicines to children under 14 years of age in Castilla y León and analyse its variability. Population and methods: A count was made of the prescriptions for the R05 therapeutic subgroup (antitussives and mucolytics) and the R01B pharmacological therapeutic subgroup (nasal decongestants for systemic use), prescribed for children under the age of 14 in the Public Health System between 2005-2010. The number of prescriptions was analysed as crude and age-adjusted rates, as well as a a multivariate analysis (Poisson regression) of the variability associated with health area, the urban/rural environment, age, and year of prescription. Results: There were 806,785 prescriptions for systemic cough and cold drugs given to an exposed population of 1,580,229 person-years. Prescription rates (per 100 person-years) were 20.7 (antitussives), 7.0 (sympathomimetic) and 23.4 (mucolytics). These drugs were employed more often in children <4 years. The prescription of mucolytics and sympathomimetics was highest at age of 1 year (rates=41.9 and 18.7, respectively) and of antitussives at 3 years (35.7). Multivariate analysis showed that in rural areas the prescription was higher than in urban areas, and that there were also significant differences between health areas. Conclusions: Between 2005 and 2010 there was a high prescription of systemic cough and cold medicines, especially in children under 2 years old, and often outside the recommended conditions of use, and there was a high geographic variabilty(AU)

[Prescription of systemic cold and cough drugs to children 0-13 years old. An unresolved problem]. / Prescripción de fármacos anticatarrales de uso sistémico a niños de 0-13 años. Un problema no resuelto.

INTRODUCTION AND OBJECTIVES: Upper respiratory tract infections are the most common cause of paediatric consultation, generating a high volume of prescriptions of drugs with unfavourable risk-benefit ratio. The aim of this study is to describe the prescription of systemic cough and cold medicines to children under 14 years of age in Castilla y León and analyse its variability. POPULATION AND METHODS: A count was made of the prescriptions for the R05 therapeutic subgroup (antitussives and mucolytics) and the R01B pharmacological therapeutic subgroup (nasal decongestants for systemic use), prescribed for children under the age of 14 in the Public Health System between 2005-2010. The number of prescriptions was analysed as crude and age-adjusted rates, as well as a a multivariate analysis (Poisson regression) of the variability associated with health area, the urban/rural environment, age, and year of prescription. RESULTS: There were 806,785 prescriptions for systemic cough and cold drugs given to an exposed population of 1,580,229 person-years. Prescription rates (per 100 person-years) were 20.7 (antitussives), 7.0 (sympathomimetic) and 23.4 (mucolytics). These drugs were employed more often in children <4 years. The prescription of mucolytics and sympathomimetics was highest at age of 1 year (rates=41.9 and 18.7, respectively) and of antitussives at 3 years (35.7). Multivariate analysis showed that in rural areas the prescription was higher than in urban areas, and that there were also significant differences between health areas. CONCLUSIONS: Between 2005 and 2010 there was a high prescription of systemic cough and cold medicines, especially in children under 2 years old, and often outside the recommended conditions of use, and there was a high geographic variabilty.

Versatilidad clínica del pseudotumor inflamatorio en Urología / Clinical Versatility of the Inflammatory Pseudotumor in Urology

Objetivo: El pseudotumor inflamatorio es una lesión rara, de comportamiento benigno y cierta heterogeneidad histológica que aparece en el tracto genitourinario. Se revisan una serie de pseudotumores inflamatorios urogenitales poniendo especial énfasis en sus características clínico-patológicas e inmunohistoquímicas. Material y métodos: Análisis retrospectivo de la casuística tratada entre enero de 1981 y diciembre de 2010 que identifica los casos de pseudotumor inflamatorio de localización urogenital. Se analizan las variables edad, sexo, clínica, topografía y tratamiento, y las características anatomopatológicas e inmunohistoquímicas de cada caso. Resultados: Se describen un total de 8 casos de pseudotumor inflamatorio de localización urogenital, de los cuales 6 se localizaron en la vejiga, uno en el riñón y uno en el epidídimo. La edad media de los pacientes fue 46,75 (± 19,84) años. Los síntomas de presentación tumoral fueron hematuria macroscópica, monosintomática o acompañada de sintomatología del tracto urinario inferior y masa inguino-escrotal. En cuanto al tratamiento en los casos de localización vesical se realizó resección transuretral± cistectomía; el caso de localización renal se trató mediante pielotomía y exéresis y el de localización epididimaria mediante exéresis simple. El estudio anatomopatológico evidenció pseudotumor inflamatorio en todos los casos, de aspecto mesenquimal y mixoide con células fusiformes de citoplasma eosinófilo, con presencia de frecuentes células inflamatorias. El patrón inmunohistoquímico más común mostró positividad para actina músculo-específica (HHF-35), vimentina y negatividad para proteína S-100. ALK-1 resultó positivo en el 87,5% de los casos. Conclusión: El pseudotumor inflamatorio es una entidad de buen pronóstico que, con un buen diagnóstico histopatológico e inmunohistoquímico, todo urólogo debe conocer y distinguir para realizar un tratamiento quirúrgico tan conservador como sea posible (AU)

Objective: The inflammatory pseudotumor is a rare lesion, having benign behavior and some histological heterogeneity that appears in the genitourinary tract. A series of urogenital inflammatory pseudotumors are reviewed with emphasis on their clinicopathological and immunohistochemical characteristics. Material and methods: A retrospective study the causistics treated between January 1981 in December 2010 was performed. It identified the cases of inflammatory pseudotumor with urogenital localization. The variables age, gender, symptoms, topography, treatment and anatomopathological and immunohistochemical characteristics of each case were analyzed. Results: A total of 8 cases of the urogenital-located inflammatory pseudotumor are described. Of these, 6 were located in the bladder, one in the kidney and one in the epididymis. Mean age of the patients was 46.75 (±19.84) years. Tumor presentation symptoms were macroscopic hematuria, single symptom or accompanied by symptoms of the lower urinary tract and inguinoscrotal mass. In regards to treatment in the cases of bladder localization, transuretheral ± cystectomy were performed. In the case of kidney localization, treatment was made by means of pyelotomy and exeresis, and in the case of epididymis localization, simple exeresis was performed. The anatomopathological study showed inflammatory pseudotumor in every cases, having a mesenchymal and myxoid appearance, with fusiform cells of eosinophil cytoplasm, with presence of frequent inflammatory cells. The most common immunohistochemical pattern shows positivity for the muscle-specific actin (HHF-35), vimentin and negativity for protein S-100. ALK-1 was positive and 87.5% of the cases. Conclusion: The inflammatory pseudotumor is a condition having good prognosis which, when there is a good histopathological and immunohistochemical diagnosis, every urologist should recognize and distinguish in order to carry out as conservative a surgical treatment as possible (AU)

[Clinical versatility of the inflammatory pseudotumor in urology]. / Versatilidad clínica del pseudotumor inflamatorio en Urología.

OBJECTIVE: The inflammatory pseudotumor is a rare lesion, having benign behavior and some histological heterogeneity that appears in the genitourinary tract. A series of urogenital inflammatory pseudotumors are reviewed with emphasis on their clinicopathological and immunohistochemical characteristics. MATERIAL AND METHODS: A retrospective study the causistics treated between January 1981 in December 2010 was performed. It identified the cases of inflammatory pseudotumor with urogenital localization. The variables age, gender, symptoms, topography, treatment and anatomopathological and immunohistochemical characteristics of each case were analyzed. RESULTS: A total of 8 cases of the urogenital-located inflammatory pseudotumor are described. Of these, 6 were located in the bladder, one in the kidney and one in the epididymis. Mean age of the patients was 46.75 (± 19.84) years. Tumor presentation symptoms were macroscopic hematuria, single symptom or accompanied by symptoms of the lower urinary tract and inguinoscrotal mass. In regards to treatment in the cases of bladder localization, transuretheral ± cystectomy were performed. In the case of kidney localization, treatment was made by means of pyelotomy and exeresis, and in the case of epididymis localization, simple exeresis was performed. The anatomopathological study showed inflammatory pseudotumor in every cases, having a mesenchymal and myxoid appearance, with fusiform cells of eosinophil cytoplasm, with presence of frequent inflammatory cells. The most common immunohistochemical pattern shows positivity for the muscle-specific actin (HHF-35), vimentin and negativity for protein S-100. ALK-1 was positive and 87.5% of the cases. CONCLUSION: The inflammatory pseudotumor is a condition having good prognosis which, when there is a good histopathological and immunohistochemical diagnosis, every urologist should recognize and distinguish in order to carry out as conservative a surgical treatment as possible.

Vesiculectomía con prostatectomía parcial laparoscópica en el tratamiento del adenocarcinoma primario de vesícula seminal con transformación carcinomatosa del conducto eyaculador / Vesiculectomy with laparoscopic partial prostatectomy in the treatment of primary adenocarcinoma of the seminal vesicle with carcinomatous transformation of the ejaculatory duct

Introducción: El adenocarcinoma primario de la vesícula seminal es una condición extremadamente rara. Se han descrito algunos casos en relación con quistes congénitos de la vesícula seminal, que a menudo se asocian también con agenesia o disgenesia renal ipsilateral. La rareza de este tipo de lesiones dificulta la planificación de un planteamiento quirúrgico reglado de las mismas, aunque habitualmente se tratan mediante exéresis simple o exenteración, según el estadio de las mismas al comienzo. Material y métodos: Presentamos una nueva técnica quirúrgica, consistente en vesiculectomía radical asociada a prostatectomía parcial laparoscópica (segmentaria total) de la zona central para tratar con éxito un adenocarcinoma primario de vesícula seminal en un varón joven, al que se le detectó por un estudio de azoospermia. Resultados: El estudio de imagen mediante resonancia magnética (RM) con difusión y la biopsia transrectal de la masa permitió una evaluación preoperatoria minuciosa del caso, confirmando malignidad y la precocidad de la lesión. El abordaje laparoscópico permitió llevar a cabo linfadenectomía pélvica y exéresis transperitoneal, incluyendo la zona central prostática y suturando la cara posterior de la uretra a la altura del ápex prostático. La lesión quística seminal confirmó en su pared un adenocarcinoma de células claras infiltrante, y el segmento prostático de la glándula central un adenocarcinoma no invasivo en la luz del conducto eyaculador con crecimiento in situ. Así, el espécimen quirúrgico permitió la exéresis radical con márgenes negativos, garantizando el carácter de cirugía mínimamente invasiva, con preservación de la continencia y de la erección. Conclusión: Se describe un nuevo abordaje integral para el planteamiento quirúrgico radical del adenocarcinoma primario de vesícula seminal localizado. A pesar de su carácter excepcional, el caso permite llevar a cabo una doble reflexión: a) el estudio de difusión con RM puede sugerir el diagnóstico de malignidad en este tipo de lesiones; y b) el tratamiento quirúrgico radical debe incluir la exéresis de la porción central de la glándula prostática (AU)

Introduction: Primary adenocarcinoma of the seminal vesicle is an extremely rare condition. Some cases have been described in relation to congenital seminal vesicle cysts, which is often also associated with agenesia or ipsilateral renal disgenesia. The rareness of this type of lesions makes it difficult to plan a regulated surgical approach for them, although they are often treated by simple exeresis or exenteration, depending on their stage at the beginning. Materials and methods: We present a new surgical technique that consists of radical vesiculectomy associated with laparoscopic partial prostatectomy (total segmentary) of the central area to successfully treat primary seminal vesicle adenocarcinoma in a young man who was diagnosed through an azoospermia study. Results: A study of the scan (MRI) with diffusion and the transrectal biopsy of the mass allowed us to make a thorough preoperative evaluation of the case, confirming the malignity and precociousness of the lesion. The laparoscopic approach allowed us to perform a pelvic lymphadenectomy and transperitoneal exeresis, including the central prostate area and suture of the posterior face of the urethra at the height of the apex of the prostate. The wall of the seminal cyst lesion confirmed infiltrating clear cell adenocarcinoma and non-invasive adenocarcinoma in the prostate segment of the central gland in the light of the ejaculatory conduct with ‘‘in situ’’ growth. Thus, the surgical specimen allowed radical exeresis with negative margins, guaranteeing minimally invasive surgery with preservation of continence and erection. Conclusion: We describe a new integral approach for the radical surgery of localized primary adenocarcinoma of the seminal vesicle. Despite its exceptional nature, the case allowed for a double reflection: a) The study of diffusion with MRI may suggest the diagnosis of malignity in this type of lesions; and b) Radical surgical treatment must include exeresis of the central portion of the prostate gland (AU)

[Vesiculectomy with laparoscopic partial prostatectomy in the treatment of primary adenocarcinoma of the seminal vesicle with carcinomatous transformation of the ejaculatory duct]. / Vesiculectomía con prostatectomía parcial laparoscópica en el tratamiento del adenocarcinoma primario de vesícula seminal con transformación carcinomatosa del conducto eyaculador.

INTRODUCTION: Primary adenocarcinoma of the seminal vesicle is an extremely rare condition. Some cases have been described in relation to congenital seminal vesicle cysts, which is often also associated with agenesia or ipsilateral renal disgenesia. The rareness of this type of lesions makes it difficult to plan a regulated surgical approach for them, although they are often treated by simple exeresis or exenteration, depending on their stage at the beginning. MATERIALS AND METHODS: We present a new surgical technique that consists of radical vesiculectomy associated with laparoscopic partial prostatectomy (total segmentary) of the central area to successfully treat primary seminal vesicle adenocarcinoma in a young man who was diagnosed through an azoospermia study. RESULTS: A study of the scan (MRI) with diffusion and the transrectal biopsy of the mass allowed us to make a thorough preoperative evaluation of the case, confirming the malignity and precociousness of the lesion. The laparoscopic approach allowed us to perform a pelvic lymphadenectomy and transperitoneal exeresis, including the central prostate area and suture of the posterior face of the urethra at the height of the apex of the prostate. The wall of the seminal cyst lesion confirmed infiltrating clear cell adenocarcinoma and non-invasive adenocarcinoma in the prostate segment of the central gland in the light of the ejaculatory conduct with "in situ" growth. Thus, the surgical specimen allowed radical exeresis with negative margins, guaranteeing minimally invasive surgery with preservation of continence and erection. CONCLUSION: We describe a new integral approach for the radical surgery of localized primary adenocarcinoma of the seminal vesicle. Despite its exceptional nature, the case allowed for a double reflection: a) The study of diffusion with MRI may suggest the diagnosis of malignity in this type of lesions; and b) Radical surgical treatment must include exeresis of the central portion of the prostate gland.

Detección y estadificación molecular del cáncer vesical mediante RT-PCR a tiempo real para gelatinasas (MMP-2, MMP-9) y TIMP-2 en sangre periférica / Detection and Molecular Staging of Bladder Cancer Using Real-Time RT-PCR for Gelatinases (MMP-2, MMP-9) and TIMP-2 in Peripheral Blood

La estadificación molecular del cáncer vesical basada en la detección de ARNm de genes específicos de urotelio no ha sido concluyente. Analizamos si la evaluación de gelatinasas (MMP-9, MMP-2) y TIMP-2 en sangre periférica mediante RT-PCR a tiempo real permite diagnosticar y caracterizar pacientes con neoplasia vesical. Material y método: Se ha extraído ARN total a partir de células sanguíneas circulantes en 42 individuos (11 controles sanos, 31 pacientes con cáncer vesical en diversos estadios) y se ha llevado a cabo RT-PCR a tiempo real empleando cebadores específicos para MMP-9, MMP-2, TIMP-2 y 18S ribosomal. Los valores de cuantificación del ARNm se describen como relativos a ARNm 18S (método ΔΔCt comparativo) y los resultados se comparan de forma ciega con los datos obtenidos mediante diagnóstico histológico y estadificación clínica. Resultados: Los niveles normalizados de ARNm de MMP-9 y MMP-2 son más altos en pacientes con cáncer que en controles (1,82±0,6veces y 2,7±0,6veces, respectivamente; p<0,05). Los pacientes con enfermedad metastática también tienen niveles mayores de ARNm de MMP-9, MMP-2 y TIMP-2 (9,6±0,20veces, 5,22±0,26veces y 1,97±0,22veces, respectivamente; p<0,05). MMP-9 y MMP-2 también se asocian con estadio clínico y grado avanzado (p<0,05). Se propone un índice entre variables que aumenta la habilidad para segregar pacientes con tumores Ta, T1, T2-4M0 y T2-4M1. Conclusiones: La identificación de tumor vesical y la estadificación molecular de la enfermedad resulta posible mediante la detección de gelatinasas y TIMP-2 en sangre periférica empleando RT-PCR a tiempo real. La capacidad de distinguir enfermedad metastásica es mayor para MMP-9, pero MMP-2 discrimina mejor los niveles de invasión tumoral. La investigación futura en este campo podría aportar resultados prometedores en la evaluación molecular de la neoplasia vesical (AU)

Introduction: Molecular staging of bladder cancer based on the detection of mRNA of urothelial specific genes in circulating cancer cells has been inconclusive. We analyze whether real-time RT-PCR evaluation of gelatinases (MMP-9, MMP-2) and TIMP-2 in peripheral blood to diagnose and characterize patients with bladder neoplasm. Material and method: Total RNA is extracted from circulating blood cells in 42 individuals (11 healthy controls, 31 patients with bladder cancer of different stages) and real-time RT-PCR performed using specific primers for MMP-9, MMP-2, TIMP-2 and ribosomal 18S. The quantification values of mRNA are described as relative to 18S mRNA (ΔΔCt method) and the results are blindly compared with data obtained from histological diagnosis and clinical staging. Results: Normalized levels of MMP-9 and MMP-2 mRNA are higher in patients with cancer than controls (1.82±0.6-fold and 2.7±0.6-fold, respectively; P<0.05). Patients with metastatic disease also have increased MMP-9, MMP-2 and TIMP-2 mRNA levels (9.6±0,20-fold, 5.22±0.26-fold and 1,97±0,22-fold, respectively; P<.05). MMP-9 and MMP-2 are also associated with advanced clinical stage and grade (P<0.05). A ratio between variables that increases the ability to segregate patients with Ta, T1, T2-4M0 and T2-4M1 tumours is proposed. Conclusions: Both non-invasive bladder tumor recognition and molecular staging of the disease is possible using real-time RT-PCR-based detection of gelatinases and TIMP-2 in peripheral blood. The ability to distinguish metastatic disease is higher for MMP-9 but MMP-2 discriminates better levels of tumour invasion. Further investigation in this field could yield promising results regarding molecular evaluation of bladder neoplasia (AU)

[Detection and molecular staging of bladder cancer using real-time RT-PCR for gelatinases (MMP-2, MMP-9) and TIMP-2 in peripheral blood]. / Detección y estadificación molecular del cáncer vesical mediante RT-PCR a tiempo real para gelatinasas (MMP-2, MMP-9) y TIMP-2 en sangre periférica.

INTRODUCTION: Molecular staging of bladder cancer based on the detection of mRNA of urothelial specific genes in circulating cancer cells has been inconclusive. We analyze whether real-time RT-PCR evaluation of gelatinases (MMP-9, MMP-2) and TIMP-2 in peripheral blood to diagnose and characterize patients with bladder neoplasm. MATERIAL AND METHOD: Total RNA is extracted from circulating blood cells in 42 individuals (11 healthy controls, 31 patients with bladder cancer of different stages) and real-time RT-PCR performed using specific primers for MMP-9, MMP-2, TIMP-2 and ribosomal 18S. The quantification values of mRNA are described as relative to 18S mRNA (ΔΔCt method) and the results are blindly compared with data obtained from histological diagnosis and clinical staging. RESULTS: Normalized levels of MMP-9 and MMP-2 mRNA are higher in patients with cancer than controls (1.82±0.6-fold and 2.7±0.6-fold, respectively; P<.05). Patients with metastatic disease also have increased MMP-9, MMP-2 and TIMP-2 mRNA levels (9.6±0,20-fold, 5.22±0.26-fold and 1,97±0,22-fold, respectively; P<.05). MMP-9 and MMP-2 are also associated with advanced clinical stage and grade (P<.05). A ratio between variables that increases the ability to segregate patients with Ta, T1, T2-4M0 and T2-4M1 tumours is proposed. CONCLUSIONS: Both non-invasive bladder tumor recognition and molecular staging of the disease is possible using real-time RT-PCR-based detection of gelatinases and TIMP-2 in peripheral blood. The ability to distinguish metastatic disease is higher for MMP-9 but MMP-2 discriminates better levels of tumour invasion. Further investigation in this field could yield promising results regarding molecular evaluation of bladder neoplasia.

Linitis plástica intestinal, metástasis tardía de adenocarcinoma gástrico en anillo de sello / Intestinal linitis plastica, late metastases in signet-ring gastric adenocarcinoma

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[Leiomyosarcoma of the paranasal sinuses with intracranial involvement: report of a clinical case and review of the literature]. / Leiomiosarcoma de senos paranasales con extensión intracraneal: presentación de un caso clínico y revisión de la literatura.

We describe a 53 year old man with a two months history of frontal headache and right visual loss, with complete right blindness at the moment of diagnosis. Neither nasal obstruction nor endocrine symptoms were found. Computerized Tomography showed a neoplasm involving both paranasal sinuses and sellar region, with bilateral orbital extension. The patient underwent a bifrontal craniotomy with apparent complete excision. Histopathologic examination proved smooth muscle cells sarcoma (leiomyosarcoma). Clinical evolution was unfavorable, with rapid local recurrence. The patient died of cerebellar metastasis 4 months after the initial diagnosis and treatment. Leiomyosarcoma of the sinonasal tract is an unusual tumor, and we have found only 63 cases previously reported. The most frequent clinical presentation is nasal obstruction. Surgery is the treatment of choice, as far as radiotherapy or chemotherapy do not appear to slow disease progression. No relationship has been found between the aggressiveness of leiomyosarcoma of the sinonasal tract and morphologic parameters; instead, prognosis is dependent on the distribution of disease at clinical onset. Leiomyosarcoma of the sinonasal tract may be regarded as a locally aggressive neoplasm with only limited metastatic potential.

Leomiosarcomas cutáneos: estudio clinicopatológico e inmunohistoquímico de cinco casos / Cutaneous leiomyosarcomas: clinicopathological and immunohistochemical study of five cases

Objetivos: Los leiomiosarcomas superficiales (de la piel y tejido subcutáneo) son neoplasias poco frecuentes, de ditinto comportamiento biológico según se localicen en la dermis o hipodermmis. Recientemente se ha propuesto su subclasificación en dos patrones histológicos: nodular y difuso. Material y Métodos: Presentamos cinco casos de leiomiosarcomas cutáneos primarios diagnosticados en nuestro Departamento entre 1991 y 1998 y revisamos la literatura, centrándonos en los hallazgos inmunohistoquímicos y en el diagnóstico diferencial. Resultados Cuatro pacientes eran varones y uno, mujer; sus edades oscilaban entre los 34 y 85 años (media 56,6). En cuatro casos las lesiones eran solitarias, y un paciente presentó lesiones múltiples; se localizaron en las extremidades (tres en las superiores y uno en las inferiores) y en el tronco. Desde el punto de vista histológico dos tumoraciones se localizaban exclusivamente en la dermis y tres afectaban además al tejido celular subcutáneo. Se identificó un patrón de crecimiento nodular en tres casos, difuso en uno y mixto en otro. La inmunohistoquímica mostró en todos los casos positividad para al menos uno de los tres marcadores de diferenciación muscular utilizados (desmina, SMA y HHF35), siendo la actina de músculo liso (SMA) positiva en el 100 por ciento de los casos. Las queratinas y la proteína S100 fueron negativas en todos los casos, encontrándose células dendítricas S100 positivas atrapadas por el crecimiento tumoral en dos casos. En cuanto a la evolución, actualmente tres pacientes se encuentran libres de enfermedad, sin datos e recidiva o metástasis. Dos fallecieron, pero sólo uno de ellos a consecuencia de la evolución de un leiomiosarcoma cuatro años después del diagnóstico inicial. Conclusiones: Consideramos que es necesario utilizar un panel de anticuerpos amplioi en el diagnóstico de estos tumores (SMA, HHF35, desmina, proteína S100 y citoqueratinas) dada la distinta expresión de estos anticuerpos en los leiomiosarcomas. Además, en todos los casos está indicado reaizar un estrecho seguimiento clínico (AU)

[A bladder nephrogenic adenoma. A case report]. / Adenoma nefrogénico vesical. Descripción de un caso.

OBJECTIVE: To report an additional case of nephrogenic adenoma of the bladder. METHODS/RESULTS: A case of nephrogenic adenoma of the urinary bladder in a 28-year-old female is described. Patient clinical history and diagnostic imaging findings are presented. CONCLUSIONS: Nephrogenic adenoma of the bladder is a rare benign tumor with specific histological features that has been associated with previous surgery, trauma, infections and lithiasis. Although it is currently not considered to be a premalignant lesion, its rate of recurrence is high (37%-49%). The treatment of choice is by transurethral resection and yearly cytological, ultrasound and cystoscopic follow-up evaluation to detect recurrence.

[Pharyngeal chordoma]. / Cordoma faríngeo.

Chordoma is a neoplasm arising from embryonal notochord remnants. It is infrequent and rarely located at the cervical level. The diagnosis is histological and immunohistochemical tests are required to differentiate it from other neoplasms. We report a case of pharyngeal chordoma treated with a transmandibular approach. The diagnosis, treatment, and prognosis of these tumors are reviewed.