Immunohistochemical expression of Ki-67, Cyclin D1, p16INK4a, and Survivin as a predictive tool for recurrence and progression-free survival in papillary urothelial bladder cancer pTa / pT1 G2 (WHO 1973).

OBJECTIVES: To investigate the expression of several immunohistochemical (IHC) markers and their predictive ability for the recurrence-free and progression-free survival of papillary urothelial bladder cancer (UBC) pTa/pT1 G2 (WHO 1973) compared to classical anatomo-clinical variables using a multidimensional analysis. MATERIALS AND METHODS: A population-based cohort of 213 primary stage UBC (pTa/pT1) G2 (WHO 1973) was evaluated by classic anatomopathological variables and characterized by immunohistochemistry (23 IHC markers, representative of different oncogenic pathways). The most important variables as a predictor of recurrence-free and progression-free survival were selected using multidimensional statistical models, such as random survival forests and least absolute shrinkage and selection operator (. Recurrence and progression-free survival of the previously selected variables were also calculated. RESULTS: Mean follow-up was 58 ± 33.5 months. Recurrence and progression rates were 54.5% (n = 116) and 17,4% (n = 37), respectively. The most influential variables in the low recurrence-free survival were in order: number of resected tumors, high expression of Ki67 (>10%), Cyclin D1 (>10%), and low cytoplasmic staining of p16INK4a. Regarding low progression-free survival, the most important variables were Ki67 (>15%), multicentric tumor arrangement and Survivin nuclear expression (>20%). Kaplan-Meier and cox-regression model analyses showed that the variables selected by multidimensional models were able to discriminate the clinical outcome. CONCLUSIONS: Ki67 index is the most useful IHC marker, since it can improve the prediction of both recurrence and progression-free survival in papillary UBC pTa/pT1 G2 (WHO 1973). There are other markers, whose utility is specific to recurrence-free survival, such as Cyclin D1 and p16INK4a or in progression-free survival, such as Survivin.

El rojo es un problema: Reacciones cutáneas a pigmento rojo de tatuajes.

La práctica de tatuajes tienen más de 8000 años de antigüedad, existiendo un incremento continuo en la sociedad occidental en las últimos 3 décadas La introducción de una sustancia exógena en la pielpuede provocar una respuesta inmunológica en su contra, estando descritas reacciones cutáneas por hipersensibilidad a una variedad de pigmentos, las que se limitan al área de un determinado color,atribuyéndose a los materiales inyectados. El color más reportado en la literatura es el rojo, que tradicionalmente se confeccionaban a base dederivados del mercurio (cinabrio). Diversos patrones histológicos de reacción están descritos, siendo el más frecuente el liquenoide. Presentamos una serie de 10 pacientes con reacción de hipersensibilidad a tatuaje rojo, con patrón histológico predominante dereacción granulomatosa y con moderada respuesta a tratamiento. Es importante cuando se está ante un patrón granulomatoso de reacción descartar sarcoidosis sistémica e infecciones por micobacterias.

Intractable hematuria secondary to systemic amyloidosis with bladder involvement.

OBJECTIVE: To present the therapeutic management of intractable hematuria secondary to systemic amyloidosis with bladder involvement. METHODS: We describe the clinical case, the medical management, the endo-urological technique used, and the results supported by relevant published literature. RESULTS: A 50-year-old woman with a 20-year history of rheumatoid arthritis in chronic treatment with corticosteroids and non-steroidal anti-inflammatory drugs in addition to chronic renal insufficiency not requiring hemodialysis. Twenty-four hours after resection of a hepatic hydatid cyst she presented intractable hematuria. The ultrasound and CT scan showed the formation of a large blood clot in the bladder not affecting the upper urinary tract. An intra-operative cystoscopy revealed a distended bladder showing signs of inflammation with diffuse, widespread bleeding. Hemostasis was achieved and a biopsy of the mucosa was taken, associated to bladder irrigation with potassium alum as a hemostatic. Given the persistence of the hematuria, further revision in the operating room as well as blood transfusion were carried out and, due to the hemodynamic instability that could not be controlled, finally selective embolization was performed. Intravesical instillation of dimethyl sulphoxide every 72 hours was used to control any remaining hematuria. The biopsy showed bladder amyloidosis. The addition of intravenous steroids and orally administered colchicine successfully controlled the patient's clinical status. CONCLUSIONS: Secondary amyloidosis of the bladder is a condition associated with hematuria that is difficult to manage. Hematuria control is often difficult, requiring aggressive treatment in addition to more conservative approaches.

Hematuria incoercible generada en la amiloidosis sistémica con afectación vesical / Intractable hematuria secondary to systemic amyloidosis with bladder involvement

OBJETIVO: Presentar el manejo terapéutico de la hematuria incoercible generada en la amiloidosis sistémica con afectación vesical. MÉTODO: Descripción del caso clínico, el manejo médico, la técnica endourológica utilizada y de los resultados con apoyo de la literatura publicada al respecto. RESULTADOS: Mujer de 50 años con antecedentes personales de artritis reumatoide (AR) de 20 años de evolución en tratamiento crónico con corticoides y AINES así como insuficiencia renal crónica sin necesidad de hemodiálisis, que tras 24 horas de la resección de un quiste hidatídico hepático presenta hematuria incoercible. Ecografía y TAC revelan gran coágulo vesical organizado sin repercusión de la vía urinaria. La cistoscopia intraoperatoria muestra una vejiga distendida de aspecto inflamatorio con sangrado difuso generalizado. Se realiza hemostasia y toma de biopsias de la mucosa asociando al lavado vesical alumbre potásico como hemostático. Dada la persistencia de la hematuria se procede a nueva revisión en quirófano más transfusión de hemoderivados en vista de la inestabilidad hemodinámica sin lograr control de la misma por lo que se realiza embolización selectiva. Se asocia instilación vesical con DMSO cada 72 hrs. para el control de la hematuria remanente. La biopsia revela el hallazgo de amiloidosis vesical agregándose al tratamiento corticoide intravenoso y colchicina oral controlando satisfactoriamente la clínica de la paciente. CONCLUSIONES: La amiloidosis vesical secundaria es una entidad que cursa con hematuria de difícil manejo. El control de la hematuria suele ser difícil por lo que además de los tratamientos conservadores a veces requiere de tratamientos más agresivos

OBJECTIVE: To present the therapeutic management of intractable hematuria secondary to systemic amyloidosis with bladder involvement. METHODS: We describe the clinical case, the medical management, the endo-urological technique used, and the results supported by relevant published literature. RESULTS: A 50-year-old woman with a 20-year history of rheumatoid arthritis in chronic treatment with corticosteroids and non-steroidal anti-inflammatory drugs in addition to chronic renal insufficiency not requiring hemodialysis. Twenty-four hours after resection of a hepatic hydatid cyst she presented intractable hematuria. The ultrasound and CT scan showed the formation of a large blood clot in the bladder not affecting the upper urinary tract. An intra-operative cystoscopy revealed a distended bladder showing signs of inflammation with diffuse, widespread bleeding. Hemostasis was achieved and a biopsy of the mucosa was taken, associated to bladder irrigation with potassium alum as a hemostatic. Given the persistence of the hematuria, further revision in the operating room as well as blood transfusion were carried out and, due to the hemodynamic instability that could not be controlled, finally selective embolization was performed. Intravesical instillation of dimethyl sulphoxide every 72 hours was used to control any remaining hematuria. The biopsy showed bladder amyloidosis. The addition of intravenous steroids and orally administered colchicine successfully controlled the patient’s clinical status. CONCLUSIONS: Secondary amyloidosis of the bladder is a condition associated with hematuria that is difficult to manage. Hematuria control is often difficult, requiring aggressive treatment in addition to more conservative approaches

Tumores de células de Leydig de testículo Estudio anatomo-clínico de siete casos / Leydig cell tumors of the testis. Anatomo-clinic study of seven cases

Antecedentes: Los tumores de células de Leydig sonpoco frecuentes (3% de las neoplasias testiculares). Presentandos picos de incidencia, el 20% en niños y el 80% enadultos. Es bilateral en el 3% de los casos. Es frecuente asociarloa criptorquídia, atrofia testicular e infertilidad. Materialy métodos: Presentamos un estudio histopatológico,immunohistoquímico y clínico de siete casos de tumores decélulas de Leydig de testiculo diagnosticados en un periodode 9 años (1998-2007). Resultados: La edad de presentaciónclínica de nuestros casos fue variable: 22 a 67 años(media 35). Debutando como orquiepididimitis (2), hidrocele(2), infertilidad (1), ginecomastia bilateral (1) o Sindromeadrenogenital. La mayoria de los tumores estabanlocalizados en teste izquierdo (5/7). Los marcadores tumoralesen sangre fueron negativos aunque se detectaronimportantes alteraciones en los niveles hormonales sobretodo de la testosterona así como de los estrógenos y la progesterona.En TAC no se observaron lesiones metastásicasni adenomegalias. Como patologías importantes asociadasrelacionadas con su etiopatogenia están: Sd. adrenogenital(1), déficit cortical primario (por enf de Addison o hiperplasiacongénita adrenal) (1) y mielolipomas adrenales bilaterales(1). Histologicamente eran tumores muy semejantesexcepto uno que presentaba un patrón hipernefroide. Immunohistoquímicamenteexpresaron vimentina, inhibina ymelan A, apreciandose una expresión variable frente a marcadoresneuroectodérmicos; tampoco expresaron marcadoreshormonales. Conclusiones: El interés de estos casos esmostrar la complejidad de alteraciones clínicas asociadas aestos tumores, así como establecer un diagnóstico diferencialhistológico con otros tumores (AU)

Background: Leydig cell tumors are infrequent (3% oftestis neoplasms). There are two peaks of incidence: 20%developed in childhood and 80% in the adult life. They arebilateral in 3% of cases. Frequently they are associated tocryptorquidism, testicular atrophy and infertility. Materialand methods: We present a histopathologic, immunohistochemicaland clinical study of 7 cases of Leydig cell tumorof the testis diagnosed in a period of 9 years (1998-2007).Results: Age of presentation was variable: 22 to 67 years(mean 35). Clinically the presentation was orchyepididymitis(2), hydrocele (2), infertility (1), bilateral gynecomastia(1), and adrenogenital syndrome. The majority of tumorswere located in left testis (5/7); tumor markers were negative,although important alterations of hormonal levels (testosterone,estrogens and progesterone) were detected. TCscanner did not reveal metastatic deposits or adenomegalies.Pathologic diseases related to the tumors were: adrenogenitalsyndrome (1), primary adrenal cortical defect due toAddison disease or congenital adrenal hyperplasia (1) andbilateral adrenal myelolipoma (1). Histopathologically, thepattern was similar in all cases except one, that presenthypernefroid pattern. Immunohistochemically, the tumorsexpressed vimentin, inhibin and melan A, as well as a variableexpression of neuroectodermal markers. Hormonalreceptors were negative. Conclusions: The interest of thispaper is to show the complex pattern of clinical presentationof these tumors, and to establish the differential diagnosiswith other testicular tumors (AU)

[Coexistence of two germinal cell tumors, seminomatous and nonseminomatous, with an uncommon clinical presentation]. / Coexistencia de dos tumores germinales seminomatoso y no seminomatoso con una presentación clínica inhabitual.

OBJECTIVES: The existence of non seminomatous mixed germ cell tumors of the testis is a frequent event in urologic oncology. Nevertheless, the presence of both components, seminomatous and non seminomatous, in a germ cell tumor is unusual. METHODS: We present a case of pure classic seminoma of the testis with a lymph node metastasis of pure embryonal carcinoma, with confirmatory immuohistochemical study and clinical outcome of the patient. RESULTS: A 34-year-old man presented with 3 cm supraclavicular tumor. CT scan also revealed multiple metastases in lymph nodes, liver, kidney and left adrenal gland. Tumor markers were negative and the biopsy performed discovered a lymph node metastasis of embryonal carcinoma of probable testicular origin. Ultrasound revealed a 6 mm hypoechoic nodule in the right testis. Orchyectomy was performed and pathologic analysis demonstrated a tumor, 1 cm of diameter, histopathologically compatible with classical seminoma with pagetoid extension to rete testis. Albuginea and spermatic cord did not present neoplastic involvement. Currently the patient is being treated with chemotherapy. CONCLUSION: The interest of the case is to remark an unusual aggressive clinical presentation as well as to perform a bibliographic review with emphasis in the theories regarding heterogeneous differentiation and spontaneous regression of germ cell tumors of the testis.

Coexistencia de dos tumores germinales seminomatoso y no seminomatoso con una presentación clínica inhabitual / Coexistence of two germinal cell tumors, seminomatous and nonseminomatous, with an uncommon clinical presentation

Objetivos: La existencia de tumores mixtos germinales no seminomatosos es un hecho frecuente en patología oncológica urológica. Sin embargo, la presencia de componente seminomatoso y no seminomatoso en un tumor germinal es una situación infrecuente. Métodos: Presentamos un caso de un seminoma puro testicular con metástasis ganglionar por carcinoma embrionario puro con un completo estudio inmunohistoquímico diferencial y evolución clínica del paciente. Resultados: Este caso corresponde a un varón de 34 años que acude a urgencias por notar una tumoración supraclavicular de 3 cm. En TAC de control se detecta adenopatías múltiples de gran tamaño a nivel supraclavicular y retroperitoneal con metástasis (M+) numerosas a nivel pulmonar, renal, hepática y suprarrenal izquierda. Siendo los marcadores tumorales negativos en sangre, se realiza una biopsia de la adenopatía supraclavicular con diagnóstico de M+ ganglionar por carcinoma embrionario de probable origen testicular. Posteriormente se realiza ecografía testicular observándose nódulo hipoecoico en teste derecho de 6mm, realizándose orquiectomía derecha cuyo estudio histopatológico revela un tumor sólido de 1cm histologicamente tipificable como seminoma clásico con extensión pagetoide a rete testes, la albugínea y el cordón espermático estaban libres de infiltración. Actualmente el paciente esta en tratamiento quimioterápico (2º ciclo del esquema BEP -bleomicina, etopósido, y cisplatino-). Conclusiones: El interés del caso es tanto por la presentación clínica agresiva inhabitual del este tumor así como por la revisión bibliográfica donde se abordan las posibles teorías del porque los tumores de células germinales testiculares suelen presentar diversos tipos de diferenciación así como por la posible regresión espontánea de los mismos (AU)

Objectives: The existence of non seminomatous mixed germ cell tumors of the testis is a frequent event in urologic oncology. Nevertheless, the presence of both components, seminomatous and non seminomatous, in a germ cell tumor is unusual. Methods: We present a case of pure classic seminoma of the testis with a lymph node metastasis of pure embryonal carcinoma, with confirmatory immuohistochemical study and clinical outcome of the patient. Results: A 34 year old man presented with 3 cm supraclavicular tumor. CT scan also revealed multiple metastases in lymph nodes, liver, kidney and left adrenal gland. Tumor markers were negative and the biopsy performed discovered a lymph node metastasis of embryonal carcinoma of probable testicular origin. Ultrasound revealed a 6 mm hypoechoic nodule in the right testis. Orchyectomy was performed and pathologic analysis demonstrated a tumor, 1 cm of diameter, histopathologically compatible with classical seminoma with pagetoid extension to rete testis. Albuginea and spermatic cord did not present neoplastic involvement. Currently the patient is being treated with chemotherapy. Conclusion: The interest of the case is to remark an unusual aggressive clinical presentation as well as to perform a bibliographic review with emphasis in the theories regarding heterogeneous differentiation and spontaneous regression of germ cell tumors of the testis (AU)

Sarcoma de estroma endometrial. Estudio clinicopatológico e inmunofenotípico de 5 casos / Endometrial stromal sarcoma. Clinicopathologic and immunophenotypic study of 5 cases

Introducción: El sarcoma de estroma endometrial uterino es un tumor muy poco frecuente con una incidencia de 0,4 -3,4 por 100.000 mujeres, comprende menos del 1% de tumores malignos ginecológicos y el 2-5% de tumores malignos uterinos, siendo el tercer sarcoma en frecuencia después del carcinosarcoma y el leiomiosarcoma. Material y métodos: Presentamos cinco casos de sarcoma de estroma endometrial diagnosticados en un periodo de siete años con la evolución clínica de las pacientes. Resultados: Immunohistoquímicamente, estos tumores expresaban vimentina, receptores hormonales, CD10 y p53 (sarcomas de alto grado), siendo los marcadores musculares, la CK, el c-kit y ALK negativos. De estos cinco sarcomas dos de ellos eran de alto grado y tres de bajo grado (uno con diferenciación miogénica y otro combinado con áreas tipo «cordones sexuales», áreas miogénicas y áreas estromales puras). Discusión: Asimismo se plantean una serie de diagnósticos diferenciales con metodología práctica para poder caracterizar estos tumores

Introduction: Endometrial stromal sarcoma (ESS) is an infrequent neoplasm with an incidence of 0,4-3,4 cases/100.000 woman. This tumor represents less than 1% of the gynecologic malignancies as well as the 2,5% of the uterine malignant tumors being the third malignancy after carcinosarcoma and leiomyosarcoma. Patients and methods: We present five cases of endometrial sarcoma, diagnosed in a period of seven years. This study includes a complete immunohistochemical analysis as well as the follow-up of the patients. Results: Immunohistochemically, these tumors expressed vimentin, hormone receptors, CD10 and p53 (high grade sarcomas), whereas muscle markers, CK, c-Kit and ALK resulted negative. Two of the ESS were high grade tumors whereas the other three were considered low grade tumors (one with myogenic differentiation and the other combining sex cord areas, myogenic foci and pure stromal areas). Discussion: We discuss their differential diagnosis with other uterine malignant tumors

[Idiopathic granulomatous orchitis: pathologic study of one case]. / Orquitis idiopática granulomatosa: estudio anatomopatológico de un caso.

OBJECTIVE: To report one case of idiopathic granulomatous orchitis, an extremely rare disease, in a 76-year-old patient. METHODS/RESULTS: The pathology department received a testicle with the clinical/radiological diagnosis of testicular tumor. The pathologic study showed absence of neoplasias and presence of morphological findings compatible with idiopathic granulomatous orchitis. CONCLUSIONS: The idiopathic granulomatous orchitis is an entity of unknown etiology, clinically or ultrasonographically not distinguishable from testicular neoplasias, the diagnosis of which is made after orchiectomy.

Orquitis idiopática granulomatosa. Estudio anatomopatológico de un caso / Idiopathic granulomatous orchitis. Pathologic study of one case

OBJETIVO: Presentar un caso de orquitis granulomatosa idiopática, patología extremadamente infrecuente, en un paciente de 76 años. MÉTODOS/RESULTADOS: Se recibe testículo derecho con diagnóstico clínico y ecográfico de tumor testicular. En el estudio anatomopatológico se observa la ausencia de celularidad neoplásica y se aprecia hallazgos morfológicos compatibles con orquitis granulomatosa idiopática. CONCLUSIONES: La orquitis idiopática granulomatosa es una entidad de etiología desconocida, ecográfica y clínicamente no distinguible de una neoplasia testicular, llegándose al diagnóstico tras la orquiectomía

OBJECTIVE: To report one case of idiopathic granulomatous orchitis, an extremely rare disease, in a 76-year-old patient. METHODS/RESULTS: The pathology department received a testicle with the clinical/radiological diagnosis of testicular tumor. The pathologic study showed absence of neoplasias and presence of morphological findings compatible with idiopathic granulomatous orchitis. CONCLUSIONS: The idiopathic granulomatous orchitis is an entity of unknown etiology, clinically or ultrasonographically not distinguishable from testicular neoplasias, the diagnosis of which is made after orchiectom