A giant adrenal pseudocyst: case report and review of the literature.

A 45-year-old woman whose MR images revealed a lobulated, complicated cyst with septations on the superior pole of left kidney underwent retroperitoneoscopic cyst marsupialization. In pathologic examination beneath the atrophic adrenal gland, hyalinized, calcification foci cyst wall without any surrounding epithelium was seen microscopically. It was reported to be "adrenal pseudocyst".

Is the positive biopsy core percent really predictive of non-organ confined prostate carcinoma?

OBJECTIVES: In this study, we investigated the association of positive biopsy core percent (PBCP), as well as other preoperative factors, with prostate cancer outcomes in a cohort of consecutive patients with clinically localized prostate cancer who underwent RRP. METHODS: Data from 203 patients who underwent RRP from March 1993 to May 2004 for clinically organ confined prostate cancer was analysed. The correlation of preoperative serum prostate specific antigen (PSA) level, biopsy Gleason score, total number of positive biopsies and PBCP with the extent of disease at final pathology and biochemical progression were analyzed. RESULTS: The mean PBCP was 29.8+/-21.1 (median 25). Histopathological examination of the RRP specimens revealed ECE in 66 (32.5 %), SVI in 43 (21.2 %), LNI in 8 (4 %), and positive SM in 59 (29.1 %). Overall, only 9% of patients ( 18 of 203) had biochemical progression at a median postoperative follow-up of 22 months. Univariate analysis revealed serum PSA, biopsy Gleason Score, the number of positive cores and PBCP as predictive factors for extra-prostatic disease in RRP specimens. However, multivariate analysis revealed that biopsy Gleason score and serum PSA were the strongest independent predictive factors for extra-prostatic disease while percent positive biopsy cores carried significance in the prediction of ECE and SM positivity. The number of positive cores was not a predictor of non-organ confined disease. Preoperative serum PSA was the only prognostic factor for determination of biochemical failure. CONCLUSION: Gleason score is the most important and independent predictive factor for extra-prostatic disease. The percentage of cores positive for cancer has significance only in the prediction of ECE and SM positivity. Further studies are needed before routine use of PBCP as one of the important preoperative prognostic factors.

¿Es el porcentaje de afectación de los cilindros de la biopsia realmente predictivo de cáncer de próstata no órgano confinado? / Is the positive biopsy core percent really predictive of non organ confined prostate carcinoma?

OBJETIVOS: Investigamos la asociación entre el porcentaje de afectación de los cilindros de biopsia y los parámetros clínicos preoperatorios, y la evolución del cáncer de próstata en una cohorte de pacientes con cáncer de próstata localizado intervenidos mediante prostatectomía radical retropúbica (PRR) de forma consecutiva. METODOS: Análisis retrospectivo de los datos de 203 pacientes con cáncer de próstata clínicamente órganoconfinado intervenidos de PRR entre Marzo de 1993 y Mayo del 2004. Se analiza la correlación del PSA preoperatorio, el Gleason en la biopsia, el número total de biopsias positivas y el porcentaje de afectación en la biopsia con la extensión de la enfermedad en el estudio anatomopatológico final y la progresión bioquímica. RESULTADOS: El porcentaje medio de afectación de los cilindros fue de 29,8 ± 21,1 (mediana 25). El análisis anatomopatológico de los especimenes quirúrgicos reveló extensión extracapsular en 66 casos (32,5%), invasión de las vesículas seminales en 43 (21,2%), afectación ganglionar en 8 (4%) y márgenes quirúrgicos positivos en 59 (29,1%). Globalmente, sólo el 9% de los pacientes (18 de 203) presentaron progresión bioquímica con un tiempo medio de seguimiento de 22 meses. El análisis univariante reveló que el Gleason en la biopsia, el número de cilindros afectos y el porcentaje de afectación eran factores predictivos de enfermedad extraprostática en el espécimen de la PRR. Sin embargo, en el análisis multivariante el Gleason y el PSA sérico eran los factores predictivos independientes más potentes de enfermedad extraprostática, mientras que el porcentaje de afectación de las biopsias tenia significación en la predicción de extensión extracapsular y márgenes positivos. El número de cilindros no fue predictivo de enfermedad extraprostática. El PSA preoperatorio fue el único factor pronóstico para la determinación de progresión bioquímica. CONCLUSIONES: La puntuación de Gleason es el factor independiente más importante en la predicción de enfermedad extraprostática. El porcentaje de los cilindros positivo para cáncer sólo tiene significación en la predicción de extensión extracapsular y márgenes quirúrgicos positivos. Son necesarios más estudios antes de utilizar rutinariamente el porcentaje de afectación de los cilindros como uno de los factores pronósticos preoperatorios importantes

OBJECTIVES: In this study, we investigated the association of positive biopsy core percent (PBCP), as well as other preoperative factors, with prostate cancer outcomes in a cohort of consecutive patients with clinically localized prostate cancer who underwent RRP. METHODS: Data from 203 patients who underwent RRP from March 1993 to May 2004 for clinically organ confined prostate cancer was analysed. The correlation of preoperative serum prostate specific antigen (PSA) level, biopsy Gleason score, total number of positive biopsies and PBCP with the extent of disease at final pathology and biochemical progression were analyzed. RESULTS: The mean PBCP was 29.8+/-21.1 (median 25). Histopathological examination of the RRP specimens revealed ECE in 66 (32.5 %), SVI in 43 (21.2 %), LNI in 8 (4 %), and positive SM in 59 (29.1 %). Overall, only 9% of patients ( 18 of 203) had biochemical progression at a median postoperative follow-up of 22 months. Univariate analysis revealed serum PSA, biopsy Gleason Score, the number of positive cores and PBCP as predictive factors for extra-prostatic disease in RRP specimens. However, multivariate analysis revealed that biopsy Gleason score and serum PSA were the strongest independent predictive factors for extra-prostatic disease while percent positive biopsy cores carried significance in the prediction of ECE and SM positivity. The number of positive cores was not a predictor of non-organ confined disease. Preoperative serum PSA was the only prognostic factor for determination of biochemical failure. CONCLUSION: Gleason score is the most important and independent predictive factor for extra-prostatic disease. The percentage of cores positive for cancer has significance only in the prediction of ECE and SM positivity. Further studies are needed before routine use of PBCP as one of the important preoperative prognostic factors

Important preoperative prognostic factors for extracapsular extension, seminal vesicle invasion and lymph node involvement in cases with radical retropubic prostatectomy.

INTRODUCTION: Initial diagnostic evaluation may provide information about the extent of disease after radical retropubic prostatectomy (RRP). The aim of this study was to investigate the predictive value of preoperative serum prostate specific antigen (PSA) level, local disease extension identified by transrectal ultrasound (TRUS), total number of positive biopsies and percentage of positive cores for cancer, as well as TRUS Biopsy Gleason score in determining the extent of disease in radical retropubic prostatectomy specimens. MATERIALS AND METHODS: A retrospective analysis was performed on 171 patients who underwent RRP from March 1993 to February 2003 for organ confined prostate cancer and whose follow-up data was accessible. The correlation of preoperative serum PSA level, local disease extension in TRUS, the total number of positive sextant biopsies and the percent of cores positive for cancer and Gleason score at TRUS biopsy specimen with the extent of disease at final pathology (Extra-capsular extension (ECE), seminal vesicle invasion (SVI), lymph node involvement (LNI) and surgical margin (SM) status on RRP specimens) were analyzed. RESULTS: The median age of the patients was 65 years. The mean preoperative serum PSA level of all patients was 11.6+/-1.2 (median 8.6) ng/ml. Histopathological evaluation of RRP specimens revealed 60 (35%) patients with ECE, 38 (22.2%) with SVI, 7 (0.04%) with LNI, and 58 (33.9%) had positive SM. Comparing the preoperative TRUS findings and postoperative evaluation of RRP specimens, the sensitivity of TRUS in predicting the ECE was 11.8% and specificity was 96%. Sensitivity of TRUS in predicting SVI was 9.8% and its specificity was 99%. With univariate analysis (sample t-test), Gleason score, percent of cores positive for cancer, and DRE were found to be predictive factors for extra-prostatic disease in RRP specimens. But with multivariate analysis (logistic regression test) Gleason score appears to be the most important and independent predictive factor for extra-prostatic disease in RRP specimens. Serum PSA levels and percentages of cores positive for cancer were also significant predictors of non organ-confined disease found at final pathology. CONCLUSION: Gleason score is the most important and independent predictive factor for extra-prostatic disease. Serum PSA levels and percentages of cores positive for cancer are the other important but non-independent predictive factors.

Apoptotic regression of prostatic tissue induced by short-term doxazosin treatment in benign prostatic hyperplasia.

OBJECTIVES: Benign enlargement of the prostate comprises both hypertrophy and in particular hyperplasia of prostatic stromal and glandular compartments. Alpha adrenergic blockade has been shown to be effective in the management of BPH. Recent investigations have shown that this effect may in part be due to apoptosis. METHODS: A total of 29 patients who were symptomatic due to BPH were enrolled into this prospective placebo controlled, double-blind randomized study and underwent prostatectomy at the end of the 4th week. Clinical efficacy was evaluated by a set of detailed investigations. Surgical specimens were analyzed by immunohistochemistry and tissue components of stroma, smooth muscle and glandular epithelium were calculated by a software on a computer after representative areas were scanned and captured as high resolution images. Apoptosis in each tissue specimen was analyzed by Terminal Deoxynucleotidyl Transferase End Labelling (TUNEL) method utilizing Biotin-16-dUTP. RESULTS: Both groups were similar in terms of baseline evaluation in all aspects. There was a steady decline in patients' urinary complaints as evidenced by International Prostate Symptom Score System (IPSS) in the doxazosin group compared to placebo. Uroflowmetric investigations on patients revealed that maximum flow rates in the active drug group increased throughout the study. Mean PSA levels decreased by 14% at the end of the study in the doxazosin group, while it increased by 11% in the placebo group. Average stroma to epithelial ratio in the doxazosin group was 2:1 in comparison to a value of 1:1 in the placebo group. The rate of apoptosis was 2.2% and 3.2% for the epithelial and stromal compartments, respectively, in the doxazosin group, and 1.2% and 2.7% for the placebo arm. CONCLUSIONS: These data suggest apoptosis as the possible underlying molecular mechanism partly responsible for the clinical efficacy and morphological changes induced by doxazosin treatment in BPH.

Early cystic relapse of embryonal carcinoma of testis in obturator fossa.

OBJECTIVE: We report a case of embryonal carcinoma stage IIB arising from the right testis that subsequently underwent chemotherapy and retroperitoneal lymph node dissection and presented with an early cystic recurrence in the obturator fossa. METHODS: This case is reanalyzed retrospectively and literature is reevaluated for the early recurrences of testicular tumors at atypical locations. We discuss the rarity of obturator fossa as a location for early recurrences of testis tumors. RESULTS: Only one case of recurrence in obturator fossa has been reported. CONCLUSIONS: This case provides an example of the possibility of recurrence in an unpredictable short interval subsequent to proper therapies and underscores the importance of close follow-up.

Alteration of epidermal growth factor receptor expression following ischaemia of renal tissue.

This study was aimed to investigate Epidermal Growth Factor Receptor (EGF-R) expression after ischaemic injury in renal tissue and the effects of calcium channel blockers in the prevention of damage due to ischaemic insult. Simple nephrectomy was performed in a group of Sprague-Dawley rats, and kidneys were grouped according to cold ischaemia time (1, 6, 12, 24 and 48 hours, respectively) and to the type of calcium channel blockers (diltiazem and verapamil) used. EGF-R expression status was investigated in each group by immunohistochemistry on paraffin sections. Overall expression of EGF-receptor was detected in 8 (22.8%) kidneys. In terms of localization of EGF-receptor expression cortical tubular staining was detected in 8 (100%) kidneys, medullar tubular staining in (62.5%) kidneys and glomerular mesangial staining in 5 (62.5%) kidneys. There was no difference between various ischaemia times and different calcium channel blockers used. It has been concluded that hypoxia and cold ischaemia causes widespread down-regulation of EGF-receptor expression in renal tissue regardless of treatment with calcium channel blockers.

Clinical significance of nuclear p53 protein accumulation in bladder cancer.

OBJECTIVES: To investigate the correlation of nuclear p53 accumulation with disease outcome in a cohort of patients with transitional cell carcinoma of the bladder. METHODS: A total of 90 patients (11 female, 79 male) with transitional cell carcinoma of the bladder were included in this study. Tumour samples from the primary tumour were analysed by immunohistochemistry for nuclear accumulation of p53 protein. Outcome of each patient was recorded and investigated for a possible relation with p53 status. RESULTS: Nuclear p53 deposition was determined in 22 specimens. The nuclear p53 deposition was seen in less than 20% of the nuclei examined in 13 and more than 20% in 9 cases. No stromal staining was observed. Nuclear p53 deposition was present in 15.2% (7/46) of grade 2 tumours, and 34% (15/44) of grade 3 tumours (p=0.037). Stage distribution revealed 15.5% (5/33) positivity in stage pTa, 25.8% (8/31) in pT1 and 34% (9/26) in stage pT2-3 tumours. Tumours with p53 nuclear accumulation had a higher rate of recurrence and progression and shorter survival. CONCLUSION: Results of the current study indicate p53 as an important factor in determination of biological behaviour of bladder cancer.

Prognostic significance of p53 protein accumulation in stage pT1 transitional cell carcinoma of the bladder.

OBJECTIVE: Mutations in the tumour suppressor gene p53 results in the production of a mutant type, dysfunctional p53 protein which can readily be detected in the cell nucleus by immunohistochemical staining. This study aims to investigate the association of nuclear p53 protein accumulation with the clinical outcome of stage pT1 transitional cell carcinoma of the bladder which is renowned for high rates of recurrence and progression. METHODS: TUR samples of the tumours from fifty-two patients with primary stage T1 bladder cancer were analyzed immunohistochemically using the standard avidin-biotin peroxidase method for nuclear p53 accumulation. Status of p53 immunostaining was correlated with tumour recurrence, disease progression and three-year survival of each patient. RESULTS: The rate of tumour recurrence in pT1 bladder cancer was 36% in patients with tumours stained negatively for p53 protein and 78% in patients with tumours stained positively for p53 protein. Disease progression was seen in 15% of p53 (-) patients and in 56% of p53 (+) patients. CONCLUSIONS: In stage pT1 bladder tumours p53 nuclear accumulation indicates higher rates of tumour recurrence and disease progression. Accordingly, in patients who have pT1 bladder tumours with nuclear p53 accumulation, institution of more aggressive therapy should be considered and early radical therapeutic modalities should be offered to these patients.

The role of in vitro chemosensitivity tests to predict the clinical efficacy of antineoplastic agents in genito-urinary tumors.

OBJECTIVE: To develop an in vitro screening system to predict the response to treatment of common malignancies of the genito-urinary tract. MATERIAL AND METHODS: Flow cytometric analysis and cytotoxicity assays (trypan blue and lactic dehydrogenase colorimetric tests) were performed on hormone resistant prostate cancer cell line PC-3 and primary transitional cell carcinoma samples treated with different antineoplastic agents and their combinations. Apoptosis induced by different agents was also investigated by previously established criteria. RESULTS: There were 9 bladder tumors (47.4%) in the study group that displayed drug resistance to at least one antineoplastic agent. When the drugs were examined individually, there was resistance to cis-platinum in 3 patients (15.8%), methotrexate in 6 (31.6%), vinblastine in 7 (36.8%), epirubicin in 2 and adriamycin in 2 patients (10.5%). Stratification of patients according to the stage of the tumor revealed statistically significant difference between the superficial and invasive tumors in terms of drug resistance (p < 0.05). In prostate cancer cell line vinblastine treatment resulted in a significant increase in S phase fraction. Percent cytotoxicity by trypan blue exclusion test was 26.1% and was significantly higher than the control group (8.7%, p < 0.002). Also, an increase in apoptotic index after the treatment was observed (44.4% and 12.1%, respectively; p < 0.0001). CONCLUSION: Both toxicity assays showed a very good correlation (p < 0.005) and can be used to evaluate the effects of different antineoplastic agents on individual tumors.

Impact of the expression of epidermal growth factor, transforming growth factor alpha, and epidermal growth factor receptor on the prognosis of superficial bladder cancer.

OBJECTIVES: To investigate the correlation of epidermal growth factor receptor (EGFR) expression and its ligands EGF and transforming growth factor-alpha (TGF-alpha) with disease outcome in a cohort of patients with superficial bladder cancer. METHODS: Tumor samples of 21 patients with transitional cell carcinoma of the bladder were analyzed by immunohistochemistry for expression of EGFR, EGF, and TGF-alpha. Disease-related events were recorded during a routine clinical follow-up and analyzed for possible correlation with the expression status of the above-mentioned proteins. RESULTS: All Stage pT1 transitional cell carcinomas expressed EGFR, and 10 of 21 (48%) tumors showed focal areas of strong EGF and/or TGF-alpha expression. Of these, 80% with EGF positivity (8 of 10) had recurrences, whereas only 9% of patients without EGF staining (1 of 11) did so. The same pattern was observed with TGF-alpha. A strong association was confirmed between EGF/TGF-alpha positivity and tumor recurrence (P <0.005). We also found that EGF and TGF-alpha were expressed in stroma and/or around the vessels of tumor tissue in 48% and 38% of the tumors, respectively. No association was found between the recurrence rate/vascular invasion and the stromal/vascular wall expression of the growth factors. CONCLUSIONS: Expression of EGF and TGF-alpha is correlated with tumor recurrence. Also, there is the ability of vessel walls to express EGF and TGF-alpha in superficial bladder cancer. Further clarification of the impact of this expression on angioinvasion of tumor cells may be helpful in understanding the nature of local invasion and metastasis.

Cirsoid arteriovenous malformation of kidney presenting as a mass suggestive of malignancy.

This paper reports a rare case of cirsoid renal arteriovenous malformation (AVM) that showed radiological characteristics of a renal malignancy. Using only conventional procedures such as computerized tomography, the present case was misdiagnosed as a solid tumor mass and therefore radical nephrectomy was indicated. Angiographic analysis is expected to improve the accuracy of diagnosis of AVM, thus reducing the need to resort to invasive techniques.

Nuclear accumulation of mutant p53 protein: a possible predictor of failure of intravesical therapy in bladder cancer.

OBJECTIVE: To investigate the expression and importance of the nuclear accumulation of p53 in superficial transitional cell carcinoma (TCC) of the bladder and its role as a predictor of response to treatment. PATIENTS AND METHODS: Tumour samples from 30 patients (two women and 28 men, mean age 60.1 years, range 44-75) with pTa/pT1 tumours were assessed immunohistochemically using the Pab1801 monoclonal antibody and standard avidin-biotin peroxidase staining for p53 protein. RESULTS: Tumours from six patients (20%) showed nuclear accumulation of p53; five of these patients failed intravesical therapy with bacille Calmette-Guèrin (BCG) and progressed to muscle invasive and/or metastatic disease, in contrast to six of 24 patients with no detectable nuclear oncoprotein. CONCLUSIONS: The nuclear accumulation of p53 appears to be a prognostic indicator of tumour unresponsive to intravesical treatment, even with the most potent agent (BCG). Therefore, early radical treatment modalities must be seriously considered in this group of patients.

Short-term effect of digital rectal examination on serum prostate-specific antigen levels. A prospective study.

OBJECTIVE: Prostate-specific antigen (PSA) is widely used as a tumor marker in the early detection of prostate cancer. However, its value is limited by several factors such as not being specific for the cancer tissue, diurnal variations of the secretion, and changes in the serum levels observed following rectal manipulations. The effect of digital rectal examination (DRE) on serum PSA levels is still debatable. METHODS: A prospective study is conducted by utilizing the IRMA count (monoclonal) PSA assay in order to determine the effect of DRE on PSA serum levels. A total of 50 men (median age 61, range 42-75 years) who presented to our outpatient clinic for the first time with lower urinary tract outflow obstruction symptoms were included in this study. Further evaluation revealed prostate cancer in 5 patients (10%) and benign prostate hyperplasia in the others. Blood samples were drawn for a PSA assay from all patients prior to and 30 min and 24 h following DRE (PSA 1-3). RESULTS: The mean PSA values prior to and 30 min and 24 h following DRE were 4.09 +/- 0.67 range 0.2-19.47) ng/ml, 4.50 +/- 0.63 (0.15-17.75), and 4.28 +/- 0.68 (0.23-24.12) ng/ml, respectively. The median PSA levels for PSA 1, PSA 2, and PSA 3 were 2.49 +/- 4.74, 3.22 +/- 4.48, and 2.62 +/- 4.82 ng/ml, respectively. Although, there was a statistically significant increase in serum PSA levels 30 min after DRE, the clinical significance of this increase in PSA values with a mean difference of 0.4 ng/ml remains to be clarified. CONCLUSION: Although the effect of DRE on PSA levels does not appear to be clinically significant, in order to prevent any confusion, it may be the best approach to perform DRE after obtaining serum for PSA analysis.

Glutathione S-transferase and multidrug-resistant phenotype in transitional cell carcinoma of the bladder.

OBJECTIVE: To asses the role of expression of resistance phenotypes in treatment failure in patients with invasive transitional cell carcinoma of the urinary bladder, since P-glycoprotein and glutathione S-transferase pi (GST) expression are implicated in resistance to various chemotherapy agents in different tumors. METHODS: Tumor samples from P-glycoprotein and GST-pi were analyzed by immunohistochemistry. RESULTS: P-glycoprotein and GST-pi were found in 35.7 and 42.9% of the samples, respectively. In 21.4% of the samples there was simultaneous expression of both proteins. No significant impact on prediction of tumor behavior was evident on statistical analysis by any one of the protein expressions. CONCLUSION: Drug resistance in transitional cell carcinoma may be through different mechanisms. Although the small sample size of this study precludes firm conclusions, the assessment of P-glycoprotein or GST-pi expression appears to be of little value as a predictor of response to chemotherapy in this group of tumors.

Enzymatic treatment of ileal segments used for urinary tract reconstruction.

Urinary tract reconstruction by using various gastrointestinal segments is not devoid of complications which may hamper to a great extent the beneficial effects of the procedure. Intestinal mucosa is the primary site responsible for these complications and any procedure aiming at the prevention of untoward effects of intestinal interposition should abolish the absorptive and secretory functions of the mucosa. Augmentation cystoplasties by ileal segments were performed on 24 male albino Wistar rats. In 12 animals de-epithelialization of the mucosa with an enzymatic cock-tail, consisting of type I and type V collagenases and trypsin, preceded the cystoplasty. The functional capacity of the epithelium was determined by a simplified glucose absorption test in the third postoperative week. Morphological examination before the absorption test did not reveal any fibrosis or shrinkage of the ileal segments. Complete elimination of the absorptive capability in enzyme treated mucosa was found during the glucose absorption test, while a rapid and highly effective absorption was observed in the control group (p < 0.05). As a result, it seems possible to obtain intestinal segments covered with a mucosa which acquired similar characteristics to uro-epithelium, therefore closely resembling the original urinary tissues.

Antimicrobial prophylaxis in management of urinary tract stones by extracorporeal shock-wave lithotripsy: is it necessary?

OBJECTIVES: In a prospective randomized study, we evaluated the incidence of urinary tract infections following extracorporeal shock-wave lithotripsy (ESWL) and the necessity of prophylactic antibiotic administration in patients treated with this modality. METHODS: A total of 360 consecutive patients with renal and ureteric stones who had sterile urine before ESWL treatment and did not have any increased risk of infection received either a single dose of 400 mg of ofloxacin or no prophylaxis. Patients were followed by simple urine analysis and urine cultures together, with clinical evaluations. RESULTS: Only 3 patients (0.8%) had positive urine cultures at 1 week after ESWL. Two of these patients were in the antibiotic prophylaxis group. CONCLUSIONS: The incidence of urinary tract infections after ESWL is extremely low, provided that patients have sterile urine before ESWL, and prophylactic antibiotics are not required.