Conventional testicular sperm extraction (TESE) and non-obstructive azoospermia: is there still a chance in the era of microdissection TESE? Results from a single non-academic community hospital.

Spermatozoa can be retrieved in non-obstructive azoospermia (NOA) patients despite the absence of ejaculated spermatozoa in their semen because of the presence of isolated foci with active spermatogenesis. Conventional testicular sperm extraction (c-TESE) in patients with NOA has been partially replaced by micro-TESE. It is still under debate the problem regarding the higher costs related to micro-TESE when compared with c-TESE. In this study, we evaluated sperm retrieval rate (SRR) of c-TESE in naive NOA patients. Sixty-three NOA patients were referred to our centre for a c-TESE. For every subject, we collected demographic data, cause of infertility, time to first infertility diagnosis, serum levels of LH, FSH, total testosterone and prolactin. A statistical analysis was conducted to correlate all the clinical variables, the histology and the Johnsen score with the SRR. Sixty-three consecutive NOA patients with a mean age of 37.3 years were included. The positive SRR was 47.6%. No statistical differences were observed between positive vs. negative SRR regarding mean FSH (17.12 vs. 19.03 mUI/mL; p = 0.72), and LH (9.72 vs. 6.92 mUI/mL; p = 0.39) values. Interestingly, we found a statistically significant difference in terms of time to first infertility diagnosis (+SRR vs. -SRR; 44.5 vs. 57 months; p = 0.02) and regarding to age (+SSR vs. -SRR; 40.1 vs. 35.3; p = 0.04). There was a statistically significant decrease in SRRs with the decline in testicular histopathology from hypospermatogenesis to maturation arrest, and SCO. The mean Johnsen score was 5.9 with a mean percentage of Johnsen score ≥8 tubules equal to 19%. The overall pregnancy rate was 26.6%. In our prospective cohort of patients successful SRR with c-TESE was 47.6%. Lower costs and high reproducibility of this technique still support this procedure as an actual reliable option in NOA patients for sperm retrieval.

Is there a role for FDG-PET for the assessment of treatment efficacy in Wilms' tumor? A case report and literature review.

BACKGROUND: The role of FDG-PET in Wilms' tumor has not been well established. The aim of this report is to describe the role of FDG-PET to assess chemotherapy efficacy and to show potential correlations between different Standardized Uptake Values (SUVs) and histopathological features in a patient with persisting metastatic disease. CASE DESCRIPTION: A 3-year-old boy was diagnosed with Wilms' tumor without anaplasia. The patient underwent treatment as according to the AIEOP-TW-2003 protocol, for stage III tumors. Therapy was discontinued with no evidence of disease, yet 9 months later thorax metastases were found. Although second and third line treatments were administered, conventional imaging demonstrated stable disease. Metronomic chemotherapy as well was employed for 44 months and FDG-PET was annually performed basing on responsible local physician choice trying to better describe the disease status. Four months after fourth line treatment was stopped, the patient manifested clinical symptoms; lesions began to increase their metabolic activity inhomogeneously. Therapy was hence restarted and SUVs decreased. Metastasectomies were then performed and histology revealed a correlation between viable disease shown by higher FDG-PET uptake and viable tumor areas. CONCLUSIONS: Our case discussion demonstrates that FDG-PET is potentially valuable in Wilms' tumor correlating SUV values and histological features of the tumor after chemotherapy. This case suggests that FDG-PET is a valid tool to assess chemotherapy response in relapsed Wilms' tumor even in case of no evidence of significant dimensional changes under conventional imaging.

Late-onset sporadic ataxia, pontine lesion, and retroperitoneal fibrosis: a case of Erdheim-Chester disease.

A 60-year-old man with progressive gait ataxia and mild pyramidal signs showed at MRI a pontine lesion with post-contrast enhancement in the left middle cerebellar peduncle. Diagnosis of Erdheim-Chester disease (ECD), a rare non-Langerhans cell histiocytosis, was suggested, further supported by a previously diagnosed retroperitoneal fibrosis. X-ray films demonstrated characteristic bilateral and symmetric osteosclerosis of the long bones of the lower limbs, which at radionuclide studies exhibited a marked increase in technetium-99 uptake. A cerebral 18FDG-PET showed a relevant pontine uptake of the tracer. Re-evaluation of a past retroperitoneal biopsy showed an intense CD68+, CD1a-, and S100- infiltrate of histiocytes with foamy cytoplasm, thus confirming the diagnosis. ECD should be regarded as a rare cause of adult-onset sporadic ataxia, especially when pontine lesions and extraneurological manifestations are present.

Phase transition in poly(vinylidene fluoride) investigated with micro-Raman spectroscopy.

The phase transition from the non-polar alpha-phase to the polar beta-phase of poly(vinylidene fluoride) (PVDF) has been investigated using micro-Raman spectroscopy, which is advantageous because it is a nondestructive technique. Films of alpha-PVDF were subjected to stretching under controlled rates at 80 degrees C, while the transition to beta-PVDF was monitored by the decrease in the Raman band at 794 cm(-1) characteristic of the alpha-phase, along with the concomitant increase in the 839 cm(-1) band characteristic of the beta-phase. The alpha-->beta transition in our PVDF samples could be achieved even for the sample stretched to twice (2x-stretched) the initial length and it did not depend on the stretching rate in the range between 2.0 and 7.0 mm/min. These conclusions were corroborated by differential scanning calorimetry (DSC) and X-ray diffraction experiments for PVDF samples processed under the same conditions as in the Raman scattering measurements. Poling with negative corona discharge was found to affect the alpha-PVDF morphology, improving the Raman bands related to this crystalline phase. This effect is minimized for films stretched to higher ratios. Significantly, corona-induced effects could not be observed with the other experimental techniques, i.e., X-ray diffraction and infrared spectroscopy.

Congenital misalignment of pulmonary vessels and alveolar capillary dysplasia: how to manage a neonatal irreversible lung disease?

Congenital misalignment of pulmonary vessels (MPV) with alveolar capillary dysplasia is a rare condition consisting of anomalous veins in bronchovascular bundles, a decreased number of alveolar capillaries, and increased muscularization of pulmonary arterioles. In the literature, infants reported as having such a malformation developed respiratory distress with persistent pulmonary hypertension and ultimately died. We report the case of an infant with MPV and alveolar capillary dysplasia who was unresponsive to maximal cardiorespiratory support, including high-frequency oscillatory ventilation and inhaled nitric oxide; the infant died of pulmonary hemorrhage after 19 days, during venoarterial extracorporeal membrane oxygenation bypass. We conclude that the diagnosis of MPV and alveolar capillary dysplasia should be considered during autopsy of infants who have died of irreversible persistent pulmonary hypertension. If a lung biopsy in infants with prolonged refractory hypoxemia confirms such diagnosis before death, expensive and invasive treatments such as extracorporeal membrane oxygenation could be avoided.

Intravesical instillation of mitomycin-C in 242 patients with superficial bladder cancer at high risk of recurrence: long-term results.

OBJECTIVE: The present study evaluated the long-term results of intravesical mitomycin C (MMC) instillation after transurethral resection (TUR) in 242 consecutive patients with superficial bladder cancer at high risk of recurrence (stage Ta, grade 1-3, or stage T1, grade 1 and 2, primary multiple or recurrent tumor). MATERIALS AND METHODS: 242 patients were treated with weekly instillations of 40 mg MMC for 8 weeks after TUR. Tumor-free patients then followed a maintenance course with monthly instillations for 3 months. RESULTS: Median follow-up of disease-free patients is 43.5 (range 23-112) months. The incidence of first recurrence is 59.5% (144/242 patients) with a median time to first recurrence of 29 months. 95 patients (39.3%) remained disease-free. Three had disease progression as the first event. The risk of recurrence was significantly higher for multifocal tumors (p = 0.0023, hazard ratio 1.79, 95% CI 1.23-2.59). Overall, patients have been followed for a median time of 57 (range 10-114) months. During this period the recurrence rate was 4.9. Eleven more patients had disease progression. The progression rate is 5.8% (14/242), with a mean time to progression of 34 months. At present 209 patients are alive, 6 have died of bladder cancer, 16 of causes unrelated to the disease and 11 (4.5%) have been lost to follow-up. Thus the crude survival rate is 86.4%, disease-specific mortality 2.5%, and non-disease-specific mortality 6.6%. CONCLUSIONS: Patients with multiple tumors seem to benefit the least from MMC instillation. Probably recurrent disease could be better prevented with intravesical bacillus Calmette-Guérin.

[Multifocal renal carcinoma: anatomic-clinical aspects]. / Carcinoma renale plurifocale: aspetti anatomo-clinici.

Between 1992 and 1996 we examined 387 kidneys after nephrectomy for renal cell carcinoma. The capsules were removed and the kidneys were serially sectioned at 5 mm intervals; cortical and intraparenchymal nodules were examined histologically. Of the 387 kidneys 12 (3%) contained multifocal renal cell carcinoma and only 3 with clinically overt tumor ut to 3 cm. in diameter. We conclude that partial nephrectomy should be widely accepted in patients with small renal cell carcinoma in presence of a normal controlateral kidney.

[Conservative surgery of parenchymal renal carcinoma: urologic data from Lombardy]. / Chirurgia conservativa del carcinoma renale parenchimale: i dati dell'urologia Lombarda.

We report the results of a questionnaire sent to various Urology departments in Lombardy about "Conservative Surgery in Renal Cell Carcinoma" which was the subject of discussion at the 50th meeting of the Lombardian Society of Urologist. 23 centres out of 34 i.e. 68% answered. 100% of the departments performed nephron sparing surgery, 91% in cases of imperative and elective indication and 9% only in imperative indication. 100% of the patients underwent preoperative staging with ultrasound and computer tomography. 48% treated in elective surgery only incidentally asintomatic discovered tumours, but 52% treated both incidentally and sintomatic ones. Elective surgery is suggested when the tumor has a diameter less than or up to 3 cm., from 3 to 5 cm., and more than 5 cm. in 48%, 48% and 4% of the urological departments respectively. 70% consider the importance of tumor location and do not perform partial nephrectomy when the tumor is intraparenchymal or in contact with the secretory tract. From a technical point of view 82% carried out partial nephrectomies while 18% carried out enucleation; 57% performed routinally frozen section on tumor bed and 61% do not performed lymphadenectomy. 83% believe in the multifocality problem. A macroscopic and microscopic haematuria does not condition the elective indication in 62% of the urology departments. The follow-up is carried out with ultrasonography alternated with CT in 78% of the departments and is continued for over 5 years in a likewise 52%. From 1990 to 1995, 3332 patients were surgically treated for renal cell carcinoma in 23 urology departments; 487 (14.6%) underwent nephron sparing surgery; 320 elective and 167 imperative indication. The local global relapse was 2.9% (14/487); 5.3% (9/167) in imperative group and 1.4% (5/320) in elective group. Conservative surgery in Lombardy will always try to have the golden standard treatment in the incidental, single renal cell carcinoma.

[A case of a urachal fistula]. / Su di un caso di fistola dell'uraco.

The authors report a case of urachal fistula diagnosed after repeated omphalitis, this disease was associated with coronal hypospadias. Diagnosis was done thanks to a fistulography; subsequently, during the operation, to evidence the fistula, this was injected with methylene blue, this expedient showed that the fistula was longer than that disclosed from fistulography. To carry out a complete extirpation of the fistula the authors were bound to make a cystotomy. The course after operation was good and the patient discharged after a few days. After 5 years the patient is in perfect health. This case allowed some anatomic, clinical and semeiotic considerations.

[Precancerous lesions of the penis]. / Le lesioni pre-cancerose del pene.

Premalignant penile lesions have been associated to squamous cancer, although the true incidence of progression of these entities to squamous cell carcinoma is unknown. These lesions may coexist with or may antecede the occurrence of carcinoma. For this reason close follow-up of the patient is necessary to detect early evidence of malignant degeneration.

Autoptic findings in HIV-1 positive children.

The growing incidence of AIDS in children and newborns has been related to increasing incidence of AIDS in women. Case records were composed by 14 children with death occurring at different ages--from 1 hour to 12 years--and 1 female fetus, all with serological confirmation of AIDS. Brain and internal organs samples were collected at autopsy for morphological, immunohistochemical and "in situ" hybridization's technical examination. The prevailing extracerebral pathology observed at autopsy consisted of opportunistic infections. The cerebral findings were HIV-encephalopathy; cytomegalovirus encephalitis; vascular alterations such as necrosis and hemorrhage; calcifications and edema. Neurologic symptoms were reported in 3 children of intravenous drug-abuser mothers as drug withdrawal syndrome. HIV positivity in one or both the intravenous drug-abuser parents is the main risk factor of congenital AIDS. This factor means lack of care during the gestational stage and may determine relevant differences in the course of disease. The cerebral changes due to opportunistic infection must be differentiated from HIV-specific lesions; it has to be stressed that "diffuse" leukoencephalopathy is not AIDS-specific but can be found in every chronic encephalitis/encephalopathy especially in newborns and children. Chronologically, HIV encephalopathy appears as late manifestation of the disease, due to an infiltration of CNS of HIV-infected macrophages and not to an impairment of neuronal or glial cells infected by HIV in the early stages of the disease.

Evidence of clonal progression in a case of Richter syndrome.

BACKGROUND: The debate continues as to whether Richter syndrome should be defined as non-Hodgkin lymphoma (NHL) because of a more malignant clone of neoplastic cells superimposed on preexisting chronic lymphocytic leukemia (CLL) or as the chance occurrence of two unrelated tumors. The cellular characteristics of the neoplastic clone involved in the CLL phase and the subsequent NHL were investigated in a patient in whom Richter syndrome developed. METHODS: Cell analysis was performed with immunofluorescence, histologic analysis, DNA extraction, and Southern blot analysis. RESULTS: The separated CLL and NHL B-cells from blood and bone marrow, as well as the neoplastic cells in autopsy specimens of the organs affected by NHL, particularly the brain, were found to express the same light chain of surface immunoglobulin (SIg). The change MD-->M in the SIg heavy-chain expression and the appearance of cytoplasmic IgMk suggested isotype switching simulating that observed on the final phases of primary B-cell differentiation. This hypothesis was confirmed by Southern blot analysis of DNA from blood cells in the CLL phase and in Richter transformation, which showed that the two cell populations had identical Ig gene rearrangement. CONCLUSIONS: The NHL in the patient in this study represented a malignant progression of CLL, not a second lymphoid malignancy.

[Pathology of the internal organs and central nervous system in acquired immunodeficiency syndrome (with special reference to opportunistic infections)]. / La patologia degli organi interni e del sistema nervoso centrale nella sindrome da immunodeficienza acquisita (con particolare riferimento alle infezioni opportunistiche).

Extracerebral and cerebral pathology in AIDS (with particular emphasis on the opportunistic infections). The Authors present the extracerebral pathology of 27 cases of AIDS observed at the Department of Pathology of Milan and the cerebral pathology of 80 cases of AIDS collected by three Institutes (Department of Pathology of Milan, Department of Pathology of Rimini and Department of Neuropathology of Münster) with particular emphasis on the pathology of the opportunistic infections. In the adults' group, the most frequent infections are the protozoan ones (T. gondii) followed with equal incidence by the viral and fungal diseases. In the pediatric group the viral diseases are the most frequently seen. Almost all of the adults show multiple infections in the same organ or in different organs. Diffuse lesions with heavy pathologic fields were observed also without tissue reaction. As to cerebral pathology AIDS' patients with opportunistic infections show focal symptoms, whereas the so called "subacute microglial encephalitis" generally appears as a demential syndrome. In cases with progressive multifocal leukoencephalopathy JC virus was always found and in one case also SV 40 - and BK virus. The diffuse demyelinization in some cases of HIV-Encephalopathy is aspecific. In HIV-positive newborns with cerebral signs, the lesions are characterized by oedema, spongiosis and microcalcifications of the basal ganglia; these are aspecific lesions which can be found in toxic and infectious encephalopathies.

Cerebral listeriosis in adults. Three cases report.

The Authors describe three autoptic cases of meningoencephalitis in adults due to an emerging pathogen, the Gram-positive bacillus Listeria monocytogenes. Only one of these was an immunosuppressed patient (recurrent carcinoma of the larynx and bladder papillomas), while no severe cause of debilitation was detected in the other two cases, excluding colonic diverticulosis in both. The post-mortem examination revealed leptomeningitis and encephalitis. Lympho-monocytic tissue reaction with perivascular cuffing was present in all the cases. The etiologic agent, L. monocytogenes, was identified by cultures from clinical or autoptic specimens.

[Endometrial morphological changes in intrauterine device users]. / Modificazioni morfologiche endometriali nelle portatrici di dispositivi intrauterini.

PIP: The diminution of the number of births seems to stem from a widespread use of voluntary abortions and only partially from a correct use of contraceptive methods. The IUD is not without clinical complications, such as hemorrhage, pelvic or endometrial inflammation, possibly ectopic pregnancy, perforation of the uterus, and loss of the IUD itself. In several out-patient clinics in the province of Novara Italy the morphological and/or morpho-functional alterations of the endometrium were analyzed histologically and evaluated on a percentage basis after removal of the IUD and examination of adhering endocervical or endometrial tissue fragments. The total sample comprised 50 patients between the ages of 20 and 46. Removal of the IUD was performed between the 1st and 3rd theoretical date of the menstrual cycle. In 60% of the patients sufficient endometrial material revealed, under the morphological aspect, that 50% had superficial inflammation and pseudodeciduation, 46% superficial dysplasia of the epithelium, 8% papillary formation, 4% superficial microthrombosis and 26% granular tissue and/or exudative material. Under the functional aspect, the endometrium was in the regular menstrual phase, as expected, for 20% of these patients, 18% in the proliferative and 18% in the secretory phase. The anomalous or phase-altering function and morphological alteration of the endometrium reacting to the presence of an extraneous device is probably one of the reasons for the contraceptive efficacy of the IUD. These well-documented endometrial and endocervical alterations do not contraindicate the use of the IUD but regular clinical and cytologic checkups are advised.^ieng