Successful Management of Angioinvasive Deep Fungal Infections of the Penis: A Multidisciplinary Approach with Intraoperative Frozen Margins.

BACKGROUND Mucormycosis, a cause of opportunistic infections in immunocompromised patients, is rarely identified in the penis. The literature often describes drastic surgical interventions or rapid patient demise, with scant mention of surgical management specifics. The objective of this report is to detail our experience with this unique infection and highlight the utility of intraoperative frozen margins during surgical management. CASE REPORT Herein, we describe successful treatment of a 55-year-old man with biopsy-proven B-cell acute lymphoblastic leukemia (B-ALL) undergoing Hyper-CVAD (Cyclophosphamide, Vincristine, Adriamycin, and Dexamethasone) therapy who initially presented with an asymptomatic violaceous lesion of the penis. Differential diagnoses ranged from infectious, vasculogenic, and pharmacologic in nature. Ultimately, a punch biopsy tissue culture confirmed angioinvasive fungal infection with Rhizopus and Fusarium species. Initial debridement combined with intravenous antifungal therapy was unsuccessful. However, partial penectomy with use of intraoperative frozen margins, a 5-week course of antifungal therapy, and continued B-ALL treatment allowed effective and lasting resolution of the infection, with partial penile preservation. CONCLUSIONS This case supports a multidisciplinary approach as the primary treatment for penile angioinvasive fungal infections. This includes treatment of the underlying immunocompromising condition, appropriate intravenous antifungal therapy, and urgent operative debridement. This report highlights the importance of utilizing intraoperative frozen sections to ensure negative margins and to optimize overall tissue sparing in this anatomically sensitive area.

Testicular epidermoid cyst: A rare case.

Testicular epidermoid cysts are a rare cause of testicular pathology. No cases of recurrence or metastasis have been reported in the literature. As a result, inguinal partial orchiectomy with frozen section has recently become standard treatment. A 43-year-old male presented with right testicular discomfort and the presence of mass. Right inguinal partial orchiectomy with frozen section was performed, and the right testicle was preserved. The final pathology report confirmed the diagnosis of an epidermoid cyst. The importance of accurate diagnosis of this benign lesion is crucial for the prevention of unnecessary radical orchiectomy.

Racial and economic disparities in the treatment of penile squamous cell carcinoma: Results from the National Cancer Database.

PURPOSE: We evaluated sociodemographic and economic differences in overall survival (OS) of patients with penile SCC using the National Cancer Data Base (NCDB). METHODS: We identified 5,412 patients with a diagnosis of penile squamous cell carcinoma from 1998 to 2011 with clinically nonmetastatic disease and available pathologic tumor and nodal staging. OS was estimated using the Kaplan-Meier method, and differences were determined using the log-rank test. Cox proportional hazard regression was performed to identify independent predictors of OS. RESULTS: Estimated median OS was 91.9 months (interquartile range: 25.8-not reached) at median follow-up of 44.7 months (interquartile range: 17.2-81.0). Survival did not change over the study period (P = 0.28). Black patients presented with a higher stage of disease (pT3/T4: 16.6 vs. 13.2%, P = 0.027) and had worse median OS (68.6 vs. 93.7 months, P<0.01). Patients with private insurance and median income≥$63,000 based on zip code presented with a lower stage of disease (pT3/T4: 11.6 vs. 14.7%, P = 0.002 and 12.0 vs. 14.0%, P = 0.042, respectively) and had better median OS (163.2 vs. 70.8 months, P<0.01 and 105.3 vs. 86.4 months, p = 0.001, respectively). On multivariate analysis, black race (hazard ratio [HR]: 1.39, 95% confidence interval [CI]: 1.21-1.58; P<0.01) was independently associated with worse OS, whereas private insurance (HR = 0.79, 95% CI: 0.63-0.98; P = 0.028) and higher median income≥$63,000 (HR = 0.82; 95% CI: 0.72-0.93; P = 0.001) were independently associated with better OS. CONCLUSIONS: Racial and economic differences in the survival of patients with penile cancer exist. An understanding of these differences may help minimize disparities in cancer care.

Nephrectomy and inferior vena cava thrombectomy for renal cell carcinoma among patients with impaired renal function: defining predictors of outcomes.

BACKGROUND: Management of renal cell carcinoma (RCC) with inferior vena cava thrombus (IVCT) is associated with high morbidity. Chronic kidney disease (CKD) is a known risk factor for perioperative complications in many surgical procedures. The objective of this study was to review the association between preoperative CKD (eGFR < 60 mL/min) and post-operative outcomes in patients with RCC and IVCT undergoing radical nephrectomy (RN) and tumour thrombectomy (TT). METHODS: A retrospective review of patients with RCC and IVCT treated with RN and TT was carried out. Complications were recorded according to the Clavien-Dindo classification. Multivariable models were fitted using logistic regression analyses for high-grade complications and salvage therapies and linear-regression for intraoperative blood loss (IBL). RESULTS: One hundred and one patients with RCC and IVCT, treated with RN and TT, were identified. Forty per cent of patients had preoperative CKD. Median IBL was higher in CKD arm (2.5 versus 1.6 L, P = 0.04). In a multivariate linear regression analysis, CKD (beta 1.34, P = 0.01) remained an independent predictor of IBL. High-grade complications were more frequent in the CKD group (34% versus 16%, P = 0.09) and in logistic regression analysis, CKD was an independent predictor of high-grade complications (OR 3.33, 95% CI 1.01-10.9). Furthermore, CKD patients were less likely to be considered for salvage therapies (62% versus 38%, P = 0.02). CONCLUSIONS: In patients treated with RN and TT, CKD is an independent predictor of perioperative morbidity. This clinical variable should be considered when selecting patients and subsequent efforts should be made to optimize other competing risk factors in order to reduce the incidence of perioperative adverse events in this patient population.

Implications of Von Hippel-Lindau Syndrome and Renal Cell Carcinoma.

Von Hippel-Lindau syndrome (VHLS) is a rare hereditary neoplastic disorder caused by mutations in the vhl gene leading to the development of tumors in several organs including the central nervous system, pancreas, kidneys, and reproductive organs. Manifestations of VHLS can present at different ages based on the affected organ and subclass of disease. In the subclasses of VHLS that cause renal disease, renal involvement typically begins closer to the end of the second decade of life and can present in different ways ranging from simple cystic lesions to solid tumors. Mutations in vhl are most often associated with clear cell renal carcinoma, the most common type of renal cancer, and also play a major role in sporadic cases of clear cell renal carcinoma. The recurrent, multifocal nature of this disease presents difficult challenges in the long-term management of patients with VHLS. Optimization of renal function warrants the use of several different approaches common to the management of renal carcinoma such as nephron sparing surgery, enucleation, ablation, and targeted therapies. In VHLS, renal lesions of 3 cm or bigger are considered to have metastatic potential and even small lesions often harbor malignancy. Many of the aspects of management revolve around optimizing both oncologic outcome and long-term renal function. As new surgical strategies and targeted therapies develop, the management of this complex disease evolves. This review will discuss the key aspects of the current management of VHLS.