Adenoid cystic carcinoma of the lacrimal gland metastatic to the kidney: case report and review of the literature.

INTRODUCTION: Adenoid cystic carcinoma (ACC) is a malignant neoplasm that arises within secretory glands. It rarely occurs in the lacrimal gland. Kidney metastases are very rare. CASE PRESENTATION: We report a case of a 76-year-old female patient treated with right radical nephrectomy because of the tumour mass of the right kidney. Well-circumscribed, firm, grey mass was found on the lower pole of the kidney. Histologically, tumour was considered to be ACC. Retrospective history data showed ACC of the lacrimal gland surgically treated 14 years before with metastasis to the lung operated seven years before. Our diagnosis was metastatic ACC to the kidney. CONCLUSION: ACC has a remarkable capacity for recurrence. To our knowledge, in the English-speaking area (PubMed), 10 cases of ACC metastatic to the kidney have been described to date, and this is the second reported case of kidney metastasis from primary lacrimal ACC.

The evolution of partial nephrectomy for kidney tumors--are we abandoning the basic principles of Robson's radical nephrectomy?

Fifty years ago, Robson introduced radical nephrectomy (RN) setting the gold standard for treating kidney tumors. Experience has shown that partial nephrectomy (PN) can be equally effective with the advantages of preserving kidney function and avoiding unnecessary nephrectomies for benign tumors. The purpose of this report is to demonstrate the evolution of clinical presentation and choice of treatment for patients with kidney tumors at our department, emphasizing changes in the PN utilization trends. Clinical data were abstracted for the years 2002, 2007 and 2012. We assessed annual trends for changes in the choice of operative treatment related to tumor size, pathologic stage and diagnosis. During the study, there was an increase in the share of T1 tumors, from 46.6% in 2002 to 69.8% in 2012. The rate of PN increased more than ten-fold, from 2.7% in 2002 to 31.7% in 2012. The annual rates of PN for T1 tumors increased even more, from 6.6% in 2002 to 46.7% in 2012. Opposite to RN group, there was an increase in the mean tumor size in PN group (from 1.8 cm in 2002 to 3.9 cm in 2012). The rate of RN for benign tumors was reduced impressively from 85.7% in 2002 to 23.1% in 2012. Our data argue strongly that PN should be expanded and not restricted. Robson's principles have been partially deserted over the last decade; however, proving that PN is superior to RN still remains to be elucidated.

Renal adenocarcinoma presenting as a spontaneous perirenal hematoma in a patient on warfarin therapy--case report and literature review.

We are presenting a rare case of a spontaneous extensive perirenal hematoma caused by ruptured renal adenocarcinoma in a patient who was on warfarin therapy because she had atrial fibrillation and three myocardial infarctions. A 77-year-old woman was admitted to our department with acute right flank pain and hemorrhagic shock. The anamnestic data revealed no trauma and hematuria. Abdominal ultrasonography and computed tomography scan showed large retroperitoneal hematoma. The patient underwent urgent surgery and radical nephrectomy was performed. A large retroperitoneal hematoma was found originating from a ruptured renal neoplasm in the upper pole of the right kidney. The pathohistological diagnosis was chromophobe renal cell carcinoma. The clinical, diagnostic and therapeutic peculiarities of this rare condition are presented, along with the literature review on the topic.

Persistence of primary MALT lymphoma of the urinary bladder after rituximab with CHOP chemotherapy and radiotherapy.

UNLABELLED: We present a case of a patient with primary extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue of the urinary bladder that persisted after chemotherapy, immunotherapy and radiotherapy. CASE REPORT: A 48-year-old male underwent a routine ultrasound examination. A tumour mass in the urinary bladder was found and a transurethral biopsy was performed. Pathohistological examination revealed MALT lymphoma. Results of computed tomographic scan, positron emission tomography scan and bone marrow biopsy defined the tumour as primary malignant lymphoma of the urinary bladder. The patient received eight cycles of chemo-immunotherapy (CHOP) and radiotherapy. Five months after therapy, there is a partial radiological remission, but with metabolic progression of the tumour. To our knowledge, this is the first case of MALT lymphoma of the urinary bladder with chemo-immunotherapy and radiotherapy resistance.

[Clinical guidelines for diagnosing, treatment and monitoring patients with testicular cancer--Croatian Oncology Society and Croatian Urology Society, Croatian Medical Association]. / Klinicke upute za dijagnostiku, lijecenje i pracenje bolesnika oboljelih od raka testisa Hrvatskoga Onkoloskog Drustva i Hrvatskoga Uroloskog Drustva Hrvatskoga Lijecnickog Zbora.

Testicular tumors are the most common solid tumors in men between 15 and 34 years of age. The worldwide incidence of these tumors has doubled in the past 40 years. Germ cell tumors comprise 95% of malignant tumors arising in the testes and they are classified either as seminoma or nonseminoma. Testicular cancers have a high cure rates even in disseminated stage of the disease. The chemotherapy mostly contributed to these results but surgery is an inevitable part of successful treatment. In a significant number of these patients treatment algorithms with minimum side effects are designed with the intention to maintain same cure rates as previously used, more aggressive therapy. The following text presents the clinical guidelines in order to standardize the procedures and criteria for diagnosis, management, treatment and follow-up of patients with testicular cancer in Republic of Croatia.

Primary osteosarcoma of bladder diverticulum mimicking intradiverticular calculus: a case report.

There is a well-documented relationship between urinary bladder diverticula and intradiverticular neoplasms. The great majorities of these tumors are urothelial carcinomas, but may also be of glandular or squamous type. Sarcomas occurring within bladder diverticula are exceptionally rare and highly malignant lesions, with only 20 well documented cases published in the literature to date (including carcinosarcomas). We report a case of osteosarcoma of the bladder diverticulum in a 68-year old man, which clinically mimicked intradiverticular calculus. To our knowledge, this is the second case described in the literature to date, and the first in English literature.

A giant hemorrhagic adrenal pseudocyst: case report.

OBJECTIVE: To report a rare case of a giant hemorrhagic adrenal pseudocyst and highlight the importance of this entity to clinicians. CASE PRESENTATION: A 57-year-old woman presented with a 1-year history of abdominal pain and distension. Ultrasonography and multislice computed tomography revealed a giant cystic (partially solid) mass over the left suprarenal region measuring 20 x 17 x 15 cm. A complete endocrine workup failed to detect any hormonal hypersecretion. INTERVENTION: The patient was treated with tumor excision through transabdominal pararectal approach. Histopathological examination revealed a hemorrhagic adrenal pseudocyst. CONCLUSION: To our knowledge the case presented here appears to be one of the largest hemorrhagic adrenal pseudocysts reported so far. Radiological and clinical features of the tumor are nonspecific and histopathological examination is essential to establish definitive diagnosis. An open, laparotomic adrenalectomy is the preferred surgical technique for better control of such a large mass with active bleeding inside.

Evolution of the clinical presentation and outcomes after radical prostatectomy for patients with clinically localized prostate cancer--changing trends over a ten year period.

We demonstrate the evolution of the clinical presentation and outcomes for patients with clinically localized prostate cancer (PC) treated with radical retropubic prostatectomy (RRP) at our department, emphasizing epidemiologic significance of changes during the 10-year period. We assessed the annual trends for changes in patients age, preoperative prostate specific antigen (PSA), preoperative versus postoperative stages and Gleason grades, organ confined status and surgical margin status. A total of 488 RRPs were performed from January 1996 to December 2005 with the annual frequency increased from 8 to 129 (1512.5%). Mean patient age increased from 61.5 to 66.12 years in 2005, with the percentage of men aged more than 70 years increased from 12.5 to 26.5%, respectively. The detection of PC based solely on pathological PSA levels (as indication for prostate biopsy) rose impressively from 25.5 to 70% and the rates of postoperative organ-confined disease also increased significantly from 25 to 74.7%. Mean preoperative PSA decreased from 16.7 to 9.89 ng/mL. On the contrary, there was an increase in percentage of patients with preoperative PSA values ranging from 4 to 10 ng/mL (from 20 to 65.4%). Positive surgical margin rate decreased from 49.4 to 25% and percent of patients receiving neoadjuvant therapy decreased from 78.5 to 5.4%. Proportion of patients who were undergraded decreased from 75.1 to 31.7%. The rates of understaging have remained relatively stable over the years. During the study period, PC was increasingly detected by prostate biopsy on the basis of a pathological PSA level only and shifted significantly to more organ-confined stages with more favourable outcomes for pathological variables due to a more accurate assessment of clinical stage prior to surgery, reduced use of neoadjuvant therapy and improved surgical technique. Our data also argue strongly that routine PSA testing should be expanded and not restricted.

The correlation between the tumor necrosis and renal artery changes in renal cell carcinoma.

Necrosis, cysts, hemorrhage, and calcification represent common findings in renal cell carcinoma. Different lesions, including arteriosclerosis or fibromuscular dysplasia, or both, may involve the main renal artery. This study analyzed the relationship between the presence and extent of necrosis in renal cell carcinoma with renal artery changes in a consecutive series of 112 patients (71 men, 41 women) with mean renal cell carcinoma of 7.7 cm (range, 2 to 20 cm). Necrosis was seen macroscopically and confirmed microscopically in 88 cases (78.6%), with 64 tumors having less than 50% and 24 more than 50% necrosis. Fibromuscular dysplasia was found in 41 patients (36.6%; 17 men, 24 women) and atherosclerotic changes in 21 patients (18.8%; 18 men, 3 women). The results suggest that necrosis of renal cell carcinoma was significantly more common in women with associated fibromuscular dysplasia (especially type I) and men with atherosclerotic changes of renal artery.

Rare case of ectopic duplicated megaureter with dysplastic upper kidney moiety opening into ipsilateral ejaculatory duct.

A rare case of left mesonephric duct malformation consisting of a duplicated ectopic megaureter opening into the ejaculatory duct and ipsilateral upper moiety cystic renal dysplasia is reported to increase awareness among urologists and radiologists of this entity. Magnetic resonance imaging has been shown to be an excellent diagnostic tool for tracking of the trajectory of the ectopic ureter, thereby obviating the need for other invasive diagnostic techniques and permitting surgical correction of the anomaly. The embryology, clinical features, and diagnostic and therapeutic aspects of this rare malformation are presented.

Systemic stress responses in patients undergoing surgery for benign prostatic hyperplasia.

OBJECTIVE: To determine differences in systemic stress responses in patients undergoing three different types of surgery for benign prostatic hyperplasia (BPH), evaluated by measuring levels of stress variables, i.e. cortisol; acute-phase reactants, i.e. C-reactive protein (CRP) and fibrinogen; and antioxidants, i.e. total antioxidant status (TAS) and superoxide dismutase (SOD). PATIENTS AND METHODS: The study included 80 patients who fulfilled the inclusion criteria for surgery for BPH. Based on an ultrasonographic estimate of the prostate volume before surgery, all patients were allocated to one of three groups; group 1, prostate < or = 30 g and treated with transurethral incision of the prostate (TUIP); group 2, prostate 30-80 g, treated with transurethral resection of the prostate (TURP); and group 3, prostate >80 g, treated with a suprapubic transvesical prostatectomy (TP). Blood samples were taken from each patient on the day before and the day after surgery, and the acute-phase reactants and antioxidants measured; cortisol concentrations were also measured in 24-h urine samples the day before and 3 days after surgery. RESULTS: There were significantly higher levels of cortisol, CRP and TAS, and significantly lower levels of fibrinogen and SOD in all study groups after surgery than before. Surgery and associated conditions, e.g. excitement, fear, blood loss, etc., lead to traumatic and oxidative stress, followed by a strong systemic stress response during and after surgery. Low fibrinogen levels after surgery had a different pattern from the other acute-phase reactants, as a result of increased fibrinolytic activity after TURP and TP. CONCLUSION: The extent of the systemic stress response correlated fairly well with the degree of tissue damage, which differed in the three groups. Suprapubic TP caused the most tissue trauma and triggered the strongest systemic stress response. This response was moderate after TURP, while TUIP (a minor intervention) caused the least stress. Specific changes in stress markers could be used to improve surgery for BPH. Whether there is a benefit of antioxidant therapy during surgery for BPH should be evaluated in further studies.

Giant testicular mixed germ cell tumor. a case report.

OBJECTIVE: We report a case that we believe to be the largest example of a testicular mixed germ cell tumor with a clearly defined histology pattern. CLINICAL PRESENTATION AND INTERVENTIONS: A 21-year-old patient consulted a urologist concerning a giant testicular mass. At the time of presentation the tumor measured 29 x 20 x 16 cm, with a weight of 4,850 g. Serum alpha-fetoprotein was over 15,000 ng/ml, while beta-human chorionic gonadotropin was normal. Chest X-ray and CT revealed multiple bilateral metastases. Histopathology revealed a mixed germ cell tumor containing 80% of yolk sack tumor, 10% of teratoma and 10% of embryonal carcinoma. Orchiectomy and chemotherapy were successful in the treatment of primary tumor and bilateral lung metastases. CONCLUSION: This tumor grew to extraordinary dimensions because of the patient's failure, due to fear, lack of knowledge and embarrassment, to seek medical help and to health professionals' negligence when performing regular check-ups.

Early diagnosis of prostate cancer in finasteride treated BPH patients.

A total of 37 patients with well-documented benign prostatic hypertrophy (BPH) were referred to finasteride. In all subjects the prostate volume was > 60 cc. Serum total PSA (TPSA) and free/total PSA (%FPSA) values were recorded at 3-month intervals. After 6 months of treatment, the patients were divided into two groups in accordance with the numerical values of these two parameters. In the first group (25 patients), a drop in TPSA approached 50% reduction while the %FPSA level remained at the initial level. No malignancy was detected in these patients after 9 months of finasteride treatment and in 4-18 months additional follow-up. The second group (12 patients), consisted of subjects with a less pronounced decrease in TPSA concentration (ca. 28%) and a significant reduction in %FPSA mostly to values < 18% (cut-off point dividing BPH from cancer) during a 6-month monitoring period. During the extended part of the investigation, prostate cancer was diagnosed in 7 out of 11 of these latter patients (63.6%), or overall in 7 out of 30 (23.3%) patients who reached the end-point of the study. Accordingly, serial assessments of total and free PSA are necessary and sufficient clinical means to detect early prostate cancer in patients with a large benign prostate referred to finasteride.

New modification of transurethral incision of the prostate in surgical treatment of bladder outlet obstruction: prospective study.

AIM: To analyze long-term effects of short and shallow incision of the prostate, a new modification of transurethral incision of the prostate (TUIP), as a method of resolving bladder outlet obstruction and preserving anterograde ejaculation and potency. METHOD: Fifty patients with symptoms of bladder outlet obstruction caused by a small benign prostate tumor of less than 30 g estimated weight were included in a nonrandomized, prospective study and underwent transurethral incision of the prostate. In the patients with normal sexual activity (n=28), short and shallow incisions were made, limited to the prostatic urethra and reaching to the fibrous capsule. In sexually inactive men (n=22), longer and deeper incisions were made, extending from below the urethral orifice upward to the verumontanum and in depth to the perivesical and periprostatic fat. All incisions were made at 5 and 7 o clock. Preoperative and postoperative evaluations performed 1, 3, 6, 12, 18, 24, 30, 36, 40, 48, 54, 60, 66, and 72 months after surgery were based on the International Prostate Symptom Scores (I-PSS), uroflowmetry, patients overall assessment of surgery outcome, and a sexual function questionnaire. RESULTS: Median follow-up was 42 months (6-72 months). There was a significant improvement in urinary peak flow rates and I-PSS decreased significantly during the follow-up period in both groups (p<0.05). Surgery outcome was rated satisfactory by all patients, with no difference between the groups. All 28 patients sexually active before the surgery retained their sexual activity after surgery; only one developed retrograde ejaculation. Two patients, one from each group, underwent further urologic treatment (transurethral resection of the prostate) 36 and 42 months after transurethral incision of the prostate, respectively. CONCLUSION: Transurethral short and shallow incision at 5 and 7 o clock is an effective method for long-term relief of bladder outlet obstruction in patients with small, benign prostate tumor. It has equally good long-term outcome as the classic long and deep transurethral incision but with fewer complications. None of the patients operated by this new method had lost potency and only a single one developed retrograde ejaculation.