Cystoscopy and mucosectomy: Essentials in the management of persistent müllerian duct syndrome with transverse testicular ectopia. / Cistoscopia y Mucosectomia: Manejo del síndrome de persistencia de los conductos mullerianos con ectopia testicular transversa.

OBJECTIVES: The concurrence of Persistent Müllerian Duct Syndrome and transverse testicular ectopia is rare. The risk of damage to the vas deferens and the deferential blood supply hinders some surgeons from complete excision of potentially malignant Müllerian duct remnants. METHODS: We present a unique surgical technique of Persistent Müllerian Duct Syndrome in a patient with right inguinal hernia accompanying transverse testicular ectopia. RESULTS: During exploration, both testes were detected in the right inguinal canal. When the hernia sac was opened, a primitive uterus and fallopian tubes without fimbria were identified confirming Persistent Müllerian Duct Syndrome. A 4 Fr catheter was placed into the os of the Müllerian duct remnants via the verumontanumorifice, and then a urethral catheter was placed. The full-thickness excision of proximal Müllerian duct remnant swere performed. The distal part of Müllerian duct remnants was layed open and only mucosa was excised for preserving vas deferens. Resection was completed just above its junction with the urethra with the aid of 4Fr catheter marked at centimeter intervals and the cuffwas oversewn. High ligation for right inguinal hernia and bilateral orchidopexy were performed. CONCLUSIONS: Removal of Müllerian duct remnantsis advised in order to reduce the jeopardy of malignancy, urinary tract infections, stones and hematuria. On the other hand, excision down to urethra which can compromise the integrity and vascularity of the vas deferens is diffucult, even in experienced surgical hands. Complete excision of these structures by mucosectomy of the distal part of remnant which lay closed to vas deferens is a safe and effective method. Cystoscopy assistance and placement of a catheter into MDRs were essential for the complete excision of this mucosa. To the best of our knowledge, cystoscopy assisted mucosectomy in Persistent Müllerian Duct Syndrome has not been reported previously.

OBJETIVOS: La presencia de síndromede persistencia de los conductos mullerianos y ectopia testicular transversa es raro. El riesgo de dañar el conducto deferente y la vascularización diversa hace que muchos cirujanos no realicen una extirpación completa de los conductos mullerianos remanentes con riesgo de malignización.MÉTODOS: Presentamos una técnica quirúrgica única para la resección completa de los conductos mullerianos remanentes en pacientes con hernia inguinal derecha acompañada de ectopia testicular transversa. RESULTADOS: Durante la exploración física se detectaron ambos testículos en el canal inguinal derecho. Cuando abrimos el saco herniario, se observó un útero primitivo con trompas de falopio sin fimbrias confirmando el síndrome de persistencia de los conductos mullerianos. Se colocó un catéter 4 Fr en la punta del remanente mulleriano a través del orificio del verumontanumy a posteriori se colocó una sonda uretral. CONCLUSIONES: La extirpación del remanente del conducto mulleriano esta indicada para evitar la malignización, infecciones urinarias, litiasis y hematuria. Por otro lado, la extirpación hasta la uretra puede comprometer la vascularización y integridad del conducto deferente, siendo dificultosa hasta en manos expertas. La extirpación completa de las estructuras con mucosectomia de la parte distal del remanente es segura y eficaz. La ayuda de la cistoscopia y colocación de un catéter en el remanente son muy importantes para la resección completa. Esta es la primera descripción de mucosectomia asistida por cistoscopia en un síndrome de persistencia del remanente mulleriano hasta la fecha.

An immunohistochemical approach to detect oncogenic CTNNB1 mutations in primary neoplastic tissues.

The Wnt/ß-catenin signaling pathway is dysregulated in different types of neoplasms including colorectal cancer (CRC). Aberrant activation of this signaling pathway is a key early event in the development of colorectal neoplasms, and is mainly caused by loss of function mutations in Adenomatous Polyposis Coli (APC), and less frequently by ß-catenin stabilization mutations via missense or interstitial genomic deletions in CTNNB1. In this study, we have defined an immunohistochemical algorithm to dissect Wnt pathway alterations in formalin-fixed and paraffin-embedded neoplastic tissues. Basically, consecutive sections of tumor specimens were stained by immunohistochemistry with two different monoclonal antibodies against ß-catenin: one (anti-active ß-catenin antibody) recognizes hypo-phosphorylated ß-catenin and the other recognizes the total pool of ß-catenin. We validated the strategy in the HCT116 CRC cell line which has an in-frame deletion of ß-catenin serine 45, and then studied human tumor microarrays containing colon adenomas, CRCs, solid pseudopapillary neoplasms of the pancreas as well as the whole tissue sections of CRCs, desmoid fibromatosis, and pilomatrixoma of the skin. In some tumors, we found strong ß-catenin cytoplasmic and/or nuclear staining with the total ß-catenin antibody but no staining with the anti-active ß-catenin antibody. This was inferred to be an altered/mutant ß-catenin staining pattern. All six colon adenomas of the 126 total adenomas studied for the altered/mutant ß-catenin staining pattern had presumptively pathogenic point mutations or deletions in CTNNB1. Four of 10 CRCs with the alterated/mutant ß-catenin staining pattern studied in depth, from 181 total CRCs from tissue microarray, had pathogenic CTNNB1 mutations. The frequencies of CTNNB1 alterations in non-colonic tumors with altered/mutant ß-catenin staining ranged between 46 and 100%. Our results demonstrate that the immunohistochemical approach described here can detect oncogenic forms of ß-catenin in primary tissue samples and can also highlight other tumors with presumptive novel defects activating the Wnt/ß-catenin pathway.

The Role of Fecal Calprotectin in Evaluating Intestinal Involvement of Behçet's Disease.

One of the regions of involvement of Behçet's disease (BD), a systematic inflammatory vasculitis with unknown etiology, is the gastrointestinal (GI) tract. Upper GI endoscopy, colonoscopy, and capsule endoscopy are frequently used methods to diagnose the intestinal involvement of BD. The aim of this study was to investigate the role of fecal calprotectin (FC) in the evaluation of intestinal involvement in BD. Material and Method. A total of 30 patients who were diagnosed with BD and had no GI symptoms and 25 individuals in the control group were included in this study. Results. Levels of FC were statistically significantly higher in patients with BD compared to the control group (p < 0.001). The correlation analysis performed including FC and markers of disease activity revealed a positive and statistically significant correlation between FC level and CRP and erythrocyte sedimentation rate (r: 0.255, p < 0.049, and r: 0.404, p < 0.001, resp.). FC levels in patients who were detected to have ulcers in the terminal ileum and colon in the colonoscopic examination were statistically significantly higher compared to the patients with BD without intestinal involvement (p = 0.01). Conclusion. The measurement of FC levels, in patients with BD who are asymptomatic for GI involvement, may be helpful to detect the possible underlying intestinal involvement.

Histopathological evaluation of orchiectomy specimens in 51 late postpubertal men with unilateral cryptorchidism.

PURPOSE: We evaluate the histopathological features of uncorrected undescended testis presenting at a late postpubertal age. MATERIALS AND METHODS: The study included 51 men (age 20 to 24 years) diagnosed with inguinal unilateral undescended testis found on routine examination for military recruits. None was evaluated or treated for undescended testis previously. All of the men had a normal contralateral testis and no other observed phenotypic alterations, and all had undergone unilateral orchiectomy. The surgical specimens were first examined histologically, and sections were additionally examined with immunohistochemical methods using antibodies against CD117 and OCT3/4 proteins to verify the presence of intratubular germ cell neoplasia. RESULTS: Histopathology revealed the presence of germ cells at different maturation levels in 26 of 51 (51%) cases. There were 28 cases (55%) with different degrees of basal membrane thickening. A decrease in seminiferous tubule diameter was observed in 23 (45%) patients. Six patients (12%) had dystrophic calcification and 12 (24%) had Leydig cell hyperplasia. Although morphological evaluation did not show intratubular germ cell neoplasia in any patients, 1 with germ cells had positivity for OCT3/4 and CD117 staining. Therefore, 1 case out of 51 had diagnosed intratubular germ cell neoplasia. CONCLUSIONS: There was a wide range of histopathological changes in undescended testis. Nearly half the patients may still have significant germ cell activity at a variety of maturation levels. The incidence of intratubular germ cell neoplasia was 2% in this group. Intratubular germ cell neoplasia may be overlooked with hematoxylin and eosin staining so immunohistochemical study should be added for evaluation.

Omentectomy for gynecologic cancer: how much sampling is adequate for microscopic examination?

CONTEXT: Detecting omental metastasis is crucial for staging and treatment of endometrial and ovarian carcinoma. OBJECTIVE: To determine the optimal omental sampling for omentectomies to ascertain the stage of the disease in a cost-effective way. DESIGN: We reevaluated 258 omentectomies that were performed due to ovarian or endometrial carcinoma. A total of 116 cases were retrospectively studied, and 142 cases were prospectively studied. For prospective study, 10 to 16 blocks were sampled if the omentum showed no signs of gross tumor. Mean omental block sample frequency of 2 groups with the negative macroscopy but with or without microscopic tumor have been compared using an independent samples t test. RESULTS: Seven patients had no evidence of tumor metastasis on gross examination but had microscopic tumor metastasis. The mean numbers of blocks were 6.4 for patients having microscopic tumor without macroscopic involvement and 7.8 for patients having neither microscopic nor macroscopic involvement. Approximately twice as many samples were taken in the prospective analysis when compared with retrospective analysis. Two cases with microscopic omental metastasis that had no macroscopic involvement at first impression were reevaluated retrospectively and found to contain 0.3- to 0.5-cm white nodules. The rate of omental metastasis increased with the grade of the tumor (P = .005). CONCLUSION: Careful macroscopic examination is the most important step in detecting small omental metastasis. For cases with gross tumor, one section is sufficient. If a macroscopic lesion is not detectable and the patient has a high-grade tumor that will necessitate an adjuvant therapy, 3 to 5 samples seem sufficient for staging. Further studies are needed to determine the optimum sample size for tumors having a low risk of metastasis.