Thyroid metastases from renal clear cell carcinoma: a cyto-histological study of two cases.

AIMS: We report about two cases of thyroid metastases, with neoplastic thrombosis of the jugular vein, originating from a renal clear cell carcinoma and arising respectively 5 and 18 years after the original nephrectomies. MAIN RESULTS AND CONCLUSIONS: The first patient had also a synchronous transitional cell carcinoma of the bladder and a poorly differentiated prostatic adenocarcinoma, further complicating the location of the primary sources of the metastases. The metastases of the first case were firstly diagnosed by mean of fine needle aspiration biopsy, and subsequently histologically confirmed. Histochemical (diffuse PAS-positive cytoplasms) and immunohistochemical stains (wide spectrum cytokeratins low molecular cytokeratins+, Ck8+, CD10+, Vimentin+, Ck20-, Ck7-, Ck19-, PSA-, thyreoglobulin-, TTF-) performed both on cytologic and histological material helped to define the metastases as oriinating from the renal clear cell carcinoma. For the first patient, the other two possible primary sources were ruled out and a possible primary thyroid tumor with clear cell change was also excluded for both patients.

[Cystic dysplasia of the testis: report of a case and review of the literature]. / Displasia cistica del testicolo: descrizione di un caso e revisione della letteratura.

Cystic dysplasia of the testis (CDT) is a rare, benign and congenital lesion causing scrotal mass in pediatric population that can mimic testicular cancer. This lesion consists of cystic dilation of the rete testis and it is frequently associated with renal or genitourinary tract anomalies as renal agenesis and multicystic dysplasia of the kidney. This frequent presentation suggests that testicular cystic dysplasia is associated with a defect of the metamesonephric system in particular with a defect in the connection between the efferent ducts derived from the mesonephros and the rete testis tubules derived from the gonadoblastoma. The role of ultrasound is of primary importance for clinical diagnosis and follow-up of untreated forms. The sonographic appearance of CDT consists of multiple cysts in the mediastinum testis. The cysts range in size from microscopic to several millimetres and may involve the whole testicular parenchyma or have a focal aspect. If the cysts are tiny, the ultrasound must be able to distinguish between CDT and testicular microlithiasis, a potential premalignant condition. Today it is possible thanks to high frequency 7.5 to 10 mHz probes. In the past orchiectomy has been considered as the treatment of the choice for CDT. Today, non operative management of CDT represents an effective alternative option in these patients and the primary benefit of this approach is the preservation of endocrine function and spermiogenic activity. However, the natural history of untreated CDT and its effect on normal testicular tissue are still unknown, therefore long-term follow-up is recommended.

[Unusual clinical presentation of bladder diverticulum: a clinical case]. / Singolare presentazione clinica di diverticolo vescicale: caso clinico.

The Authors report a rare case of bladder diverticulum with radiological findings compatible with infiltrating bladder cancer and left ureterohydronephrosis. The definitive diagnosis was possible only after surgical intervention with mass removal and histological examination that resulted compatible with bladder diverticulum producing an inflammatory pseudotumor of the wall.

[Percutaneous drainage of abdominal abscess. A clinical case and issues of operative ultrasonography in urology]. / Drenaggio percutaneo di ascesso addominale. Caso clinico e argomenti di ecografia operativa in urologia.

Percutaneous drainage of intrabdominal abscesses currently is a well established technique. The use of ultrasound, ever more frequently utilized in urology department, made urologists autonomous in ultrasound diagnosis and operative stage. We report on a patient admitted to emergency department in whom acute prostatitis was diagnosed. Urological consultation was obtained. The ultrasound examination performed, permitted to reveal the real syntomatology origin and to make an evaluation about the possible application of ultrasound in diagnosis and treatment of abdominal abscesses. This was also an occasion to re-examine some not urological ultrasound cases and their treatment. We believe that, also for the urologists, morphological knowledge of most frequent abdominal pathologies, visible by ultrasound, is useful to avoid diagnostic mistakes and useless and hazardous treatments. In our experience we confirm that percutaneous and non invasive techniques, if well utilized, have a good cost/benefit ratio. The percutaneous treatment is also useful to convert an urgent surgical operation into a well established and programmed one.

[Complicated urachal cyst: a difficult differential diagnosis]. / Cisti dell'uraco complicata: una difficile diagnosi differenziale.

Embryologically, the allantois connects the urogenital sinus with the navel. Normally, the allantois is oblitered before the birth and is represented by a fibrous cord, called urachus, extending from the dome of the bladder to the navel. Urachal formation is directly related to bladder descent. Incomplete obliteration sometimes occurs. Disease rarely occurs in urachus, but adenocarcinoma is the most fearful and rare, and it represents the 0.01% of the whole adult carcinoma, the 0.17-0.34% of the whole bladder malignancy, and the 20-30% of the bladder adenocarcinoma. Yet urachus may be seat of other kinds of benign pathologies characterized by incomplete obliteration of its lumen. Only if the ends of the urachus seal off, a cyst of that body may form and may become quite large, presenting a low midline abdomen mass. Adenocarcinoma may occur in a urachal cyst, particularly at its vescical extremity. Cystis usually have an asymtomatic course. Occasionally these cystis can be discovered during sonographic examination. If the cyst becomes infected, signs of general and local sepsis will develop, sometimes involving the peritoneum. Sometimes, in these cases, it is difficult to diagnose the presence of an adenocarcinoma and, particularly, its cystic variant. By using the common diagnostic instrumental device, we cannot reach a certain diagnosis, essential to perform a correct medical or surgical treatment. The case reported concerns a twenty-five years old man, over and over again examined, complaining of ipo-mesogastric abdominal pain, mild fever, increment of flogosis index and transaminasis, microscopic hematuria and urinal discomfort. Sonographic suprapubic examination, performed during urological consultation, showed an urachal neoplasm. Cystoscopy and TC evaluation didn't permit a certain preoperative diagnosis. A surgical explorative operation was performed and the neoplasm, a part of a bladder dome, omental flap and a part of rectus muscles, were removed. In order to reconstruct the abdominal wall we used a large Polypropilene patch. The hystological report outlined a large urachal cyst, a flogosis and a purulent necrosis invading the surrounding tissue and the peritoneum. The patient was discharged after twenty-five days and he had a good functional performance. In the light of the reported case, the surgical treatment seems to be the best solution before the onset of complications that should expose patients to difficult and demolitive surgical operations and that should protract the hospitalization.

[Early diagnosis of prostatic carcinoma by random biopsies in 60 patients clinically negative but with PSA greater than 8.9 ng/ml]. / Diagnosi precoce del carcinoma prostatico tramite biopsie random in 60 pazienti clinicamente negativi per neoplasia ma con PSA superiore a 8.9 ng/ml.

60 patients, 64 years old on average, with no evidences of prostatic cancer, but with a PSA level greater than 8.9 ng/ml, have undergone six transrectal systematic sextant biopsies. All patients had no suspicious finding on digital rectal examination. Ultrasound transrectal examinations did not show hypoechoic areas suspected of a prostatic cancer. We used an automatic biopsy gun fitted with an 18 gauge biopsy needle. Three biopsies in each lobe, at the apex, in the midline zone and at the base of the prostate, in the parasaggital plane, was performed. No complications were found during following days. Of the 60 men, with a non suspicious prostate on rectal examination, 12 had prostatic cancer. They had, on average, a PSA level of 10.8 ng/ml. The PSAD level was, on average, of 0.18 and the Gleason score was, on average, of 3.8. The patients who underwent pelvic lymphadenectomy and radical prostatectomy did not have an infiltration of the glans capsule of seminal vesicles and no lymph node metastasis were found. In our study, the digital rectal and ultrasound examination alone would have missed the 23% of prostatic cancers. Therefore, according to the literature, the PSA makes us able to discover prostatic cancer more than the clinical and instrumental evaluation alone. Furthermore the ultrasound examination presents some diagnostic limits. Particularly it is very difficult to detect small cancer arising into the hypoechoic multinodular adenoma of the transition zone. In addition 10-20% of cancers, arising into the peripheral zone, are hysoechoic with the surrounding parenchyma. For that reason, when PSA value is greater then 8.9 ng/ml without clinical or ultrasound evidence of cancer, we recommend to perform six systematic sextant biopsies. At present, the real question is to determine whether this early diagnosis is useful for patients, because there is no certainty of the therapeutic benefit in terms of quantity and quality life.

[T1G3 transitional bladder neoplasms: what to do?]. / Neoplasia vescicale transizionale T1 G3: che fare?

The treatment of T1 G3 bladder cancer is still an issue surrounded by much conflict. TUR of the bladder tumor as single treatment is considered not valid to be successful. TUR associated with intravescical chemotherapy or, even better, local immunotherapy may be the treatment of first choice in monocentric cancer, while radical cystectomy is, at the moment, the treatment of first choice in pluricentric or Cis associated T1 G3 bladder cancer. Since 1980, 25 patients with transitional T1 G3 bladder cancer have been observed in our department. Thirteen patients had a pluricentric disease while the remaining 12 cases had a monocentric bladder cancer. 92% of the patients (12/13) with a monocentric lesion and treated with TUR and local chemotherapy (Doxorubicin or BCG) are disease free after an average follow up of 34 Months (range 12-60 months). While 100% patients with a pluricentric cancer and treated with cystectomy are disease free after an average follow-up of 37 months (range 12-122 months); the 4 remaining cases with a pluricentric bladder lesion who refused cystectomy experienced a relapse of the disease after a follow-up of 19 months (range 9-27 months) and, despite surgery, they died within 12 months.

[Renal angiomyolipoma with locoregional lymph node localization associated with pulmonary tuberous sclerosis: a case report]. / Descrizione di un caso di angiomiolipoma renale con localizzazione linfonodale locoregionale associato a sclerosi tuberosa polmonare.

The angiomyolipoma is a rare tumor of the kidney with benign clinical evolution which can be found in more than half of the female patients with tuberous sclerosis. An uncommon case of renal angiomyolipoma with extracapsular extension, inter-aortocaval lymph node involvement and pulmonary lymphangiomyomatosis with a clinical history of spontaneous recurrent pneumothorax but without the neurological signs of the tuberous sclerosis, is described. The natural history of this disease which has various clinical forms of presentations is still unclear. The role of the lymph-node dissection in the surgical treatment of this tumor is discussed.