Functional Adrenocortical Carcinoma: A Rare Case With Thrombus Extension Into the Inferior Vena Cava and a Presentation of Cushing Syndrome.

Adrenocortical carcinoma (ACC) is a rare, highly malignant endocrine tumor, often associated with a poor prognosis. Most patients who develop ACC are either children of ages 1-6, or adults in their fourth to fifth decade of life. Individuals with a functional cortisol-secreting ACC frequently present with Cushing syndrome. We report a case of an 18-year-old male who was found to have a large ACC tumor, with thrombus extension into the inferior vena cava (IVC), after presenting with Cushing syndrome. ACC presents a challenging scenario for physicians as surgical resection remains the only form of curative therapy, however, despite such treatment many patients quickly develop metastases.

Outcome analysis of patients with Peyronie's disease who elect for vacuum erection device therapy.

INTRODUCTION: Peyronie's disease (PD) affects approximately 0.7-11% of men and has numerous proposed treatments. Invasive management options include surgical or injectable therapy, while penile traction therapy with vacuum erection device (VED) represents a non-invasive approach. Our objective is to assess outcomes for patients with PD who opt for non-invasive management. METHODS: We performed a retrospective analysis for patients with PD who were followed for at least three months and opted for noninvasive therapy. All patients were instructed to initiate VED traction therapy for 10 minutes twice per day. Patients were assessed for degree of PD deformity and erectile function (Sexual Health Inventory for Men [SHIM] score) at initial and subsequent encounters. RESULTS: Fifty-three patients met the inclusion criteria. The mean (standard deviation [SD]) age was 57 (12) years, and the mean (SD) duration of PD prior to assessment was 25 (15) months. The mean (SD) duration of followup was 14 (11) months. Among untreated patients who did not use a VED, nine showed improvement, 20 remained stable, and four had worsening curvature. The untreated group had a significant change in curvature, with a mean improvement (SD) of 3.6 (12)° (p=0.048). All 20 men who initiated VED traction therapy had an improvement in curvature with a significant mean (SD) improvement of 23 (16)° (p=2.6×10-6). Changes in SHIM scores did vary significantly between groups. No complications were noted. CONCLUSIONS: In patients who opt for non-invasive management of PD, VED traction therapy provides improved curvature resolution compared to those who do not use such a device. The limitations of this study include the retrospective nature and a small sample size at a single treatment center.

Classification tree for the prediction of malignant disease and the prediction of non-diagnostic biopsies in patients with small renal masses.

INTRODUCTION: Preoperative prediction of benign vs. malignant small renal masses (SRMs) remains a challenge. This study: 1) validates our previously published classification tree (CT) with an external cohort; 2) creates a new CT with the combined cohort; and 3) evaluates the RENAL and PADUA scoring systems for prediction of malignancy. METHODS: This study includes a total of 818 patients with renal masses; 395 underwent surgical resection and 423 underwent biopsy. A CT to predict benign disease was developed using patient and tumour characteristics from the 709 eligible participants. Our CT is based on four parameters: tumour volume, symptoms, gender, and symptomatology. CART modelling was also used to determine if RENAL and PADUA scoring could predict malignancy. RESULTS: When externally validated with the surgical cohort, the predictive accuracy of the old CT dropped. However, by combining the cohorts and creating a new CT, the predictive accuracy increased from 74% to 87% (95% confidence interval 0.84-0.89). RENAL and PADUA score alone were not predictive of malignancy. One limitation was the lack of available histological data from the biopsy series. CONCLUSIONS: The validated old CT and new combined-cohort CT have a predictive value greater than currently published nomograms and single-biopsy cohorts. Overall, RENAL and PADUA scores were not able to predict malignancy.

Clinical follow up and the impact of the Paris system in the assessment of patients with atypical urine cytology.

BACKGROUND: Urinary cytology is routinely used in the diagnosis of urothelial neoplasms, with good sensitivity for high-grade urothelial carcinoma (HGUC) but less so for low-grade urothelial neoplasm (LGUN). There is significant interobserver and interinstitutional variability, especially for the atypical category. The Paris system for reporting urinary cytology (TPS) was introduced to better define the various categories, especially atypical cytology. METHODS: We retrospectively reviewed 630 atypia of undetermined significance (AUS) cases and reclassified them based on TPS. In total, 501 cases previously reported as negative for malignancy had their medical records reviewed to serve as negative controls. RESULTS: Of 630 AUS cases, 299 (47.5%) were reclassified as negative for HGUC (NHGUC), 313 (49.7%) as atypical urothelial cells (AUCs) and 18 (2.9%) as suspicious for HGUC (SHGUC). Based on our institution's previous reporting system, the rate of underlying or subsequent HGUC was 2.8% for AUS, and 0% for negative. When AUS cases were reclassified under TPS, the rates were 1.5% for NHGUC, 4.8% for AUC, and 0% for SHGUC. Review of medical records showed that patients with AUS were more likely to be followed-up compared with those with negative urine cytology (77.8% compared with 54.3%), particularly those under the care of non-urologists. CONCLUSIONS: AUS diagnosis is associated with more patient follow up compared with NEG urine particularly among non-urologists. Reclassifying according to TPS results in significant reduction in the rate of AUS and thus unnecessary testing. This reduction however may be at the expense of slightly decreased detection rate of HGUC.

Oncocytic adrenocortical carcinoma: a rare adrenal tumor subtype.

Oncocytic tumors arising from the adrenal gland are rare. Oncocytic adrenal neoplasms (OAN) may mimic adrenocortical carcinoma (ACC) at presentation, and can only be definitively diagnosed histologically. Most OANs are benign, and carry a favorable prognosis. We report on an 83-year-old female who, while being investigated for anemia and weight loss, was found to have a 23 cm adrenal mass concerning for ACC. Adrenalectomy and histopathology confirmed a malignant OAN, based on the Lin-Weiss-Bisceglia criteria. We report on the largest non-functional, malignant OAN cited in the literature to date. OAN's, though rare, can be considered in the differential diagnosis of large adrenal tumors.

Gravity-assisted drainage imaging in the assessment of pediatric hydronephrosis.

INTRODUCTION: As early detection of hydronephrosis increases, we require better methods of distinguishing between pediatric patients who require pyeloplasty vs. those with transient obstruction. Gravity-assisted drainage (GAD) as part of a standardized diuretic renography protocol has been suggested as a simple and safe method to differentiate patients. METHODS: Renal scans of 89 subjects with 121 hydronephrotic renal units between January 2004 and March 2007 were identified and analyzed. RESULTS: Of all renal units, 65% showed obstruction. GAD maneuver resulted in significant residual tracer drainage in eight renal units, moderate drainage in 12 renal units, and some improvement in 40 units after the GAD maneuver. Of the eight renal units with significant residual tracer drainage, only two proceeded to pyeloplasty. After pyeloplasty, nine children had improved time to half maximum (T(1/2) Max) and 13 were unchanged. CONCLUSIONS: Our study was limited due to its retrospective design and descriptive analyses, but includes a sufficient number of subjects to conclude that GAD as part of a diuretic renography protocol is an effective and simple technique that can help prevent unnecessary surgical procedures in pediatric patients.

Utility of 18F-FDG PET in evaluating cancers of lung.

PET has seen rapid progression in recent years, with applications in oncology leading the way. The glucose analog (18)F-FDG is the most commonly used PET radiopharmaceutical and has been shown to accumulate avidly in several different neoplasms, including cancers of the lung. The following discussion will review the physiologic basis for the uptake of (18)F-FDG in lung neoplasms and demonstrate the utility of (18)F-FDG PET in lung cancer. A brief review of other PET radiopharmaceuticals in lung cancer imaging, and dual-modality PET/CT scanners, will be presented. Upon completion of this article, the reader should be able to describe the pharmacokinetics of (18)F-FDG and discuss the efficacy of (18)F-FDG PET scans in the evaluation of solitary pulmonary nodules, disease staging, and monitoring response to therapy. Additionally, the reader should be able to compare (18)F-FDG PET with conventional anatomic imaging and describe some of the technical challenges of PET/CT fusion imaging.