Twenty-year Experience with Genitourinary Lymphoma at a Community Hospital.

Introduction: Non-Hodgkin lymphoma is the seventh most common cancer in the United States. It may involve any extranodal organ, although involvement of the genitourinary (GU) tract accounts for <5% of all primary extranodal lymphomas. Published GU lymphoma literature is currently limited to small case series and case reports. The last substantial American series was published in 2009. Our objective was to characterize cases of GU lymphoma from our institution based on organ involved and to review relevant literature.Patients and Methods: After institutional review board approval, we retrospectively reviewed medical records of patients diagnosed with lymphoma involving the GU organs from 1995 through 2015. Patients with obstructive uropathy from retroperitoneal adenopathy without parenchymal involvement of a GU organ were excluded. We classified extranodal GU lymphomas as primary or secondary, based on involvement of other organs and distant lymphadenopathy.Results: Thirty-six patients had lymphoid neoplasms involving the kidney, ureters, bladder, testis, penile skin, or prostate in our health system during the study period. Of these, 15 (41.6%) were primary. Most patients initially sought consultation for GU-related symptoms, such as bladder obstruction, hematuria, testicular mass, or abdominal pain. Histological subtypes and flow cytometry findings varied broadly.Conclusion: Our series reports site-specific outcomes data and adds detail to findings from other published series. Although GU lymphomas are rare, our series confirms prior studies demonstrating presentation in urologic organs. They should be considered in the differential diagnosis in all patients, especially those with unusual findings on examination, cystoscopy, or computed tomography scan.

Evaluation of Asymptomatic Microscopic Hematuria by Renal Ultrasound to Detect Upper Tract Malignancy: A 20-Year Experience in a Community Hospital.

OBJECTIVE: To evaluate the sensitivity of ultrasound imaging in detecting upper urinary tract malignancy in patients with asymptomatic microscopic hematuria (AMH) in an outpatient community setting. MATERIALS AND METHODS: A list of all patients who received renal ultrasound for hematuria in our health care system between January 1, 1997 and July 1, 2015 was obtained, and electronic health records were retrospectively reviewed. Patients were excluded for age (<18 years), <3 years follow-up, prior upper tract malignancy, recent urinary tract catheterization, inpatient status, pregnancy, insufficient data, or gross hematuria. The initial ultrasound was considered positive if suspicious findings led to a subsequent diagnosis of an upper tract malignancy. False negatives were determined by electronic medical record follow-up for at least 3 years. RESULTS: Of the 2138 patients with AMH who met inclusion criteria, ultrasound imaging detected suspicious findings in 9 of 9 patients with renal cell carcinoma and 3 of 3 patients with upper tract urothelial cancer, indicating a sensitivity of 100% and 100%, respectively. Four additional malignancies were diagnosed more than 3 years after the initial evaluation for an incidence rate of 1.6 cases of upper tract malignancy per 10,000 person-years. CONCLUSION: The prevalence of upper urinary tract malignancy was low in patients with AMH. Ultrasonography is an appropriate modality for upper tract imaging in the initial evaluation of patients with AMH. Practice guidelines should be updated to reflect the high sensitivity of ultrasound and low risk of upper tract malignancy in patients with AMH.

A Multidisciplinary Approach to Management of Bouveret Syndrome.

Bouveret Syndrome is a rare complication of gallstone disease that occurs when a gallstone enters the stomach or bowel through a biliary enteric fistula and becomes impacted, resulting in gastric outlet obstruction. It is frequently seen in elderly chronically ill patients with neglected biliary disease. We describe a multidisciplinary approach to management of Bouveret Syndrome that could be adopted by healthcare systems with resources commonly found in facilities with a general urologist and gastroenterologist or general surgeon. Successful application of laser lithotripsy under endoscopic guidance sufficiently fractured the stone to allow for disimpaction and relief of the gastric outlet obstruction.

Genomic case report of a low grade bladder tumor metastasis to lung.

BACKGROUND: We present a rare case where distant metastasis of a low grade bladder tumor was observed. We carried out detailed genomic analysis and cell based experiments on patient tumor samples to study tumor evolution, possible cause of disease and provide personalized treatment strategies. CASE PRESENTATION: A man with a smoking history was diagnosed with a low-grade urothelial carcinoma of the bladder and a concurrent high-grade upper urinary tract tumor. Seven years later he had a lung metastasis. We carried out exome sequencing on all the patient's tumors and peripheral blood (germline) to identify somatic variants. We constructed a phylogenetic tree to capture how the tumors are related and to identify somatic changes important for metastasis. Although distant metastasis of low-grade bladder tumor is rare, the somatic variants in the tumors and the phylogenetic tree showed that the metastasized tumor had a mutational profile most similar to the low grade urothelial carcinoma. The primary and the metastatic tumors shared several important mutations, including in the KMT2D and the RXRA genes. The metastatic tumor also had an activating MTOR mutation, which may be important for tumor metastasis. We developed a mutational signature to understand the biologic processes responsible for tumor development. The mutational signature suggests that the tumor mutations are associated with tobacco carcinogen exposure, which is concordant with the patient's smoking history. We cultured cells from the lung metastasis to examine proliferation and signaling mechanisms in response to treatment. The mTOR inhibitor Everolimus inhibited downstream mTOR signaling and induced cytotoxicity in the metastatic tumor cells. CONCLUSION: We used genomic analysis to examine a rare case of low grade bladder tumor metastasis to distant organ (lung). Our analysis also revealed exposure to carcinogens found is tobacco as a possible cause in tumor development. We further validated that the patient might benefit from mTOR inhibition as a potential salvage therapy in an adjuvant or recurrent disease setting.

A Retrospective Review of Contrast Nephropathy in a General Population.

BACKGROUND: One of the adverse events associated with administration of intravenous (IV) contrast media is contrast-induced nephropathy, yet its incidence is poorly characterized. We investigated the incidence of contrast-induced nephropathy in patients with elevated baseline serum creatinine concentrations who underwent computed tomography (CT) using IV contrast media. MATERIALS AND METHODS: Using the electronic medical records at a community hospital, we retrospectively identified patients with elevated baseline serum creatinine concentrations who had undergone CT utilizing IV contrast media between January and July 2000, a period prior to the routine use of pretreatment as prophylaxis against contrast-induced nephropathy, and who subsequently developed elevated serum creatinine. We identified concomitant risk factors for the rise in serum creatinine in these patients aside from IV contrast media exposure. RESULTS: One hundred ninety-three patients with a baseline serum creatinine concentration greater than 1.2 mg/dL underwent 236 CT studies utilizing IV low-osmolar contrast media. Nine of the 193 patients had a rise in serum creatinine ≥ 0.5 mg/dL up to 1 month later. None of these 9 patients had contrast exposure as the only risk factor for their rise in serum creatinine. CONCLUSION: The role of IV contrast media in causing contrast-induced nephropathy and, thus, acute kidney injury, may be overestimated. Further study needs to be done into whether contrast-induced nephropathy is truly a common or even a real entity in patients receiving IV contrast media for routine studies who have no other risk factors for kidney injury warranting the expense, risks, and inconvenience of pretreatment.