Spontaneous rupture of adrenocortical carcinoma: a coincidence or a tendency?

We report a rare case of adrenocortical carcinoma spontaneously rupturing. To our knowledge, this is the sixth reported case in literature that is not related to any preceding traumatic incidents or predisposing disease. Upon reviewing previous cases, tumor size greater than 10 cm in adults is a predisposing factor for spontaneous rupture, while the degree of lymph node invasion or the extent of distant metastasis is not indicative. Further study is warranted to validate our finding, but we suggest that if an adrenal tumor suspicious of malignant presentation is found incidentally, the size of tumor may warrant a more aggressive approach for prevention of tumor rupture and decrease in patient morbidity and mortality.

Expression of human prostate-specific glandular kallikrein protein (hK2) in the breast cancer cell line T47-D.

Human glandular kallikrein (hK2) protein, like prostate-specific antigen (PSA), is produced mainly in prostatic epithelium. It may be useful as a new diagnostic indicator for prostate cancer. Recently, a number of hK2-specific monoclonal antibodies have been developed that enable us to detect hK2 protein in human prostate tissue, seminal fluid, and sera. Whether hK2 can be expressed, like PSA, in nonprostatic cells is not known. In this study, we have characterized the presence of hK2 in an androgen-responsive breast cancer cell line T47-D at both the protein and mRNA levels with an immunoassay, Western blot analysis, Northern blot analysis, and the reverse transcription-PCR. Using a sensitive immunoassay with monoclonal antibodies to hK2, we found that T47-D cells could be induced with androgens, mineralocorticoids, glucocorticoids, and progestins to produce significantly more hK2 than PSA. Estrogens failed to mimic the effect of the other steroids, blocking instead the stimulatory effect of androgens. Androgen induction of hK2 in T47-D cells was dose dependent. More interestingly, we found that the hK2 in androgen-induced T47-D cell spent media appears to be the pro-form of hK2 rather than mature hK2. Our study demonstrates that hK2, a serine protease thought to be found only in prostate-related tissues and fluids, is also produced in a breast cancer cell line T47-D after steroid stimulation. This finding suggests that hK2 may have a potential role in breast cancer as well as prostatic cancer and will be the impetus for further studies of hK2 distribution and function.

Interactive effects of triiodothyronine and androgens on prostate cell growth and gene expression.

T3 plays an important role in the regulation of cell growth and differentiation. In this study, we show the interactive effects of T3 and androgens on the growth response and expression of the prostate-specific genes, PSA (prostate-specific antigen) and hK2 (human glandular kallikrein), in the human prostate cancer cell line, LNCaP. T3 alone showed pronounced growth enhancement in a dose-dependent fashion. However, in the presence of androgens, higher concentrations of T3 were required to produce additional proliferative effects. T3, androgens, or a combination of the two up-regulated PSA protein production in a dose-dependent fashion, but T3 had little stimulatory effect on hK2 protein expression, regardless of the presence or absence of androgens. Using gene transfer assays, T3 alone showed no effect on transcriptional activation of a reporter gene mediated by the PSA or hK2 enhancer/promoters. T3 potentiated the androgen-mediated transcription of the PSA gene but not that of the hK2 gene. A previous study suggested that the T3 effect on PSA protein expression was caused by an up-regulation of the androgen receptor (AR) protein by T3. Our results contradict these. Although AR expression was increased by T3 alone, Western blot analysis showed that the total cellular AR level was not further increased by T3 in the presence of androgens, in comparison with cells stimulated by androgens alone. Both Western blot analysis and a gel DNA band shift assay revealed that nuclear AR was not increased by T3. This study suggests that transcription factor(s) other than the AR may mediate T3 enhancement of androgenic induction of PSA expression.

Testosterone modulates mitochondrial aconitase in the full-length human androgen receptor-transfected PC-3 prostatic carcinoma cells.

In vitro studies indicated that dihydrotestosterone (DHT) stimulates the enzymatic activity of the mitochondrial aconitase (mACON) in androgen-sensitive prostatic carcinoma cells, LNCaP. Cell proliferation assay determined that DHT doubles the optimal proliferation response of LNCaP cells. The androgen-insensitive human prostatic carcinoma cells, PC-3, were overexpressed in the human androgen receptor to assess the involvement of the native androgen receptor in the regulation by DHT of mACON gene expression. A stable-transfected clone that expresses the full-length androgen receptor was selected and termed PCAR9. The results revealed that DHT-treated PCAR9 cells paradoxically not only reduced the enzymatic activity of mACON but also blocked the biosynthesis of intracellular ATP attenuating cell proliferation. Transient gene expression assay indicated that DHT divergently regulates the promoter activity of the mACON gene in LNCaP and PCAR9 cells. This study suggested that DHT regulates mACON gene expression and the proliferation of cells in a receptor-dependent model through modulation by unidentified non-receptor factors.

Evaluation of a decision-support system for preoperative staging of prostate cancer.

The usefulness and effectiveness of a decision-support system for preoperative staging of prostate cancers (PCES) were evaluated. The study population consisted of 43 consecutive patients with the preoperative diagnosis of prostate cancer who underwent surgical operation. Results obtained using the PCES were compared with staging by four urology attending physicians and five urology residents. The effect of PCES consultation on the physicians' staging of prostate cancer was also evaluated. To confirm the usefulness of the clinical findings of prostate-specific antigen, prostate-specific antigen density, prostate volume, and abnormal Gleason score in the PCES, their receiver operating characteristic (ROC) curves for diagnosis of advanced prostate cancer were plotted. The values of the areas under the curves were 0.772, 0.800, 0.531, and 0.752. The stage of prostate cancer was correctly determined by the PCES for 38 of the 43 patients, yielding 88.4% preoperative diagnostic accuracy. The PCES was significantly more accurate than two of the attending physicians and all residents. PCES consultation improved the residents' staging accuracy to approximately that of the attending physicians. The effect of PCES consultation on the residents' staging was significantly (p < 0.001) greater than the effect on the physicians' staging. The PCES may be useful in the preoperative staging of prostate cancers, especially during residency. The system's accuracy in determining the stage of advanced prostate cancer may make it possible to avoid unneccesary surgical operations.

Enhancing mediastinal mass at MR: Castleman disease.

We report a case of an enhancing middle mediastinal mass imaged by MR and CT. Repeated nondiagnostic biopsies in this 25-yr-old male patient had resulted in profuse hemorrhage. Final pathological diagnosis after thoracotomy and debulking was Castleman disease. This is a rare, benign lymphoproliferative disorder of uncertain etiology. Histological varieties include the hyaline vascular type (80-90%) and the plasma cell type (10-20%). Cure is generally accomplished via surgical excision. This entity should be included in the differential diagnosis of enhancing mediastinal lesions, prompting awareness of the potential for bleeding complications following biopsy.

Pregnancy after intentional cryopreservation of percutaneous sperm aspiration specimens and intracytoplasmic sperm injection. A report of two cases.

BACKGROUND: Microsurgical epididymal sperm aspiration (MESA) and percutaneous epididymal sperm aspiration (PESA) are two methods of obtaining spermatozoa from patients with irreparable obstructive azoospermia. Intentionally using frozen-thawed spermatozoa obtained from MESA had been reported to be successful. With minimal invasiveness, intentionally cryopreserved PESA specimens and intracytoplasmic sperm injection (ICSI) were carried out in two cases. CASES: Two cases of irreparable obstructive azoospermia received PESA, and the spermatozoa were cryopreserved intentionally. Successful ICSI was performed later, utilizing frozen-thawed spermatozoa. CONCLUSION: PESA and ICSI are promising methods for these patients. The major advantages are minimal invasiveness and flexibility for further treatment.

Effects of a medical expert system on differential diagnosis of renal masses: a prospective study.

A medical expert system, RMDS, was used to prospectively evaluate patients undergoing nephrectomy for suspected renal masses. The effects of a medical expert system on differential diagnosis of renal masses were investigated. After RMDS consultation, three chief residents and one junior attending physician changed their preoperative diagnosis and significantly increased their diagnostic accuracy. The results indicate that the medical expert system may have an useful role in preoperative diagnosis of renal masses.

In vitro fertilization pregnancy achieved with epididymal caput sperm of a patient with obstructive azoospermia.

A successful epididymal sperm aspiration, in vitro fertilization and embryo transfer in a woman whose husband had previously undergone extensive attempts at recanalization of the spermatic ducts is reported. A twin pregnancy was achieved using sperm obtained from the husband's epididymal caput. This case demonstrates that pregnancy can be achieved by this reproductive technique in cases of obstructive azoospermia, even after extensive surgery.

High inguinal loupe-assisted varicocelectomy for subfertile men with varicococeles: technical feasibility, clinical outcomes and complications.

254 consecutive patients underwent high inguinal loupe-assisted varicocelectomy. All patients had at least a one year history of infertility with abnormal semen parameters and physical examination and/or color Doppler ultrasound proven varicocele. To facilitate the procedure, an x 3.0 loupe was used during spermatic cord dissection near or at level of internal inguinal ring. Semen analysis and physical examination were performed at 3 monthly intervals. No intra-operative complications occurred. The most common post-operative complications were transient scrotal pain and stitch reaction, occurring in 12% and 4% of men, respectively. Only one permanent and two transient hydroceles were observed. Recurrent or persistent varicocele was identified by physical examination and color Doppler in 5 varicocelectomies (1.4%), and by color Doppler only in 6 varicocelectomies (1.7%). Sperm motility increased from 30 +/- 8% to 46 +/- 20%, and sperm concentration. (10(6)/cc) increased from 24 +/- 18 to 41 +/- 28. The one-year pregnancy rate was 37%. High inguinal loupe-assisted varicocelectomy is a safe, simple, and effective treatment for varicocele.

Loupe-assisted modified one-layer vasovasostomy.

Several studies indicate that microsurgical modified one-layer vasovasostomy is comparable to the two-layer anastomosis with respect to patency and pregnancy rates. The objective of this study was to determine the feasibility and result of modified one-layer vasovasostomy under loupe magnification only. Thirty-two patients aged 28 to 64 years (mean 41.3 +/- 6 years) underwent vasovasostomy at CGMH from July 1997 to June 2002, with all operations being a modified on-layer anastomosis created with the aid of a 3 x loupe. The estimated duration of vasectomy ranged from 4 months to 27 years, with a mean of 9.2 +/- 4.8 years. Postoperative semen analysis and pregnancy were examined. Each patient was followed up at 1,4, and 12 weeks postoperatively. The total operation time ranged from 118 to 228 minutes (average 150 +/- 35 minutes). There was no operation-related complication such as hematoma or wound infection. The patency rate was 89% (25/28), and the pregnancy rate at 2 years or more of follow-up was 39% (11/28). The patency and pregnancy rates were similar to those obtained in most studies of microsurgical vasovasostomy. For uncomplicated vasectomy reversal, this simple loupe-assisted modified one-lyer vasovasostomy seems to provide an adequate anastomosis.

The rate and topography of cell wall synthesis during the division cycle of Escherichia coli using N-acetylglucosamine as a peptidoglycan label.

The rates of synthesis of peptidoglycan and protein during the division cycle of Escherichia coli were measured by the membrane elution technique using cells differentially labelled with N-acetylglucosamine and leucine. During the first part of the division cycle the ratio of the rates of protein and peptidoglycan synthesis was constant. The rate of peptidoglycan synthesis, relative to the rate of protein synthesis, increased during the latter part of the division cycle. These results support a simple, bipartite model of cell surface increase in rod-shaped cells. Prior to the start of constriction the cell surface increases only by lateral wall extension. After cell constriction starts, the cell surface increases by both lateral wall and pole growth. The increase in surface area is partitioned between the lateral wall and the pole so that the volume of the cell increases exponentially. No variation in cell density occurs, because the increase in surface allows a continuous exponential increase in cell volume that accommodates the exponential increase in cell mass. The results are consistent with the constant density of the growing cell and the surface stress model for the regulation of cell surface synthesis. In addition, the elution pattern suggests that the membrane elution method does work by having the cells effectively bound to the membrane by their poles.

Mode of peptidoglycan synthesis in Salmonella typhimurium: single-strand insertion.

The synthesis of peptidoglycan by Salmonella typhimurium at the molecular level has been analyzed by studying the pattern of insertion of newly synthesized strands into the preexisting cell wall. We have measured the acceptor-donor radioactivity ratio during short labeling periods, and we found values between 0 and 0.2. This is less than the ratio observed by Burman and Park (Proc. Natl. Acad. Sci. USA, 81:1844-1848) for peptidoglycan synthesis in Escherichia coli. We propose that insertion of new strands occurs as single strands.

Retained vaginal gauze with unusual complication: a case report.

We report a case of a postpartum retained vaginal gauze which migrated to the bladder and presented as a bladder stone. The patient had received numerous clinical evaluations for her chronic abdominal pain, of all which failed to detect or indicate the presence of retained gauze. Retained surgical gauze is a preventable problem but continues to occur periodically. Prevention remains the key to this problem. The gauze packed within the vagina either after transvaginal surgery or delivery should be cared for as in other parts of the body. Though extremely rare, retained surgical gauze should be considered in the differential diagnosis in postpartum patients with chronic abdominal pain, irritable bladder symptoms or pelvic abscess.

Laparoscopic drainage for the treatment of posttransplant lymphocele.

Lymphocele following renal transplantation may be associated with ureteral obstruction, venous obstruction, venous thrombosis, infection and pain. Drainage of lymphocele is indicated when these complications arise or if the patient is symptomatic from the size and pressure of the lymphocele. Less invasive methods for the treatment of lymphocele, including simple needle aspiration, external drainage and sclerotherapy, are associated with an unacceptably high incidence of recurrence and complications. Internal drainage is the treatment of choice either via the retroperitoneal transplant incision or transperitoneally through abdominal incision. We now report a case of posttransplanted lymphocele that was successfully drained into the peritoneal cavity using laparoscopy. We believe this is an effective alternative route to provide internal drainage for lymphoceles.

Diagnosis of prostate cancer: comparison of serum prostate specific antigen, digital rectal examination and transrectal ultrasonography.

BACKGROUND: While prostate specific antigen (PSA) is useful as a tumor marker for monitoring patients with prostate cancer after definitive therapy, limitations have been noted when it is used for early detection of prostate cancer. METHODS: We reviewed the charts of 121 patients who had undergone prostate needle biopsies, documented digital rectal examination (DRE) and serum PSA determination before biopsy from January 1993 to October 1994. Indications for biopsy included abnormal DRE. PSA level greater than 4.0 ng/ml or abnormal lesions on transrectal ultrasonography (TRUS). RESULTS: Seventeen patients (14%) had stage A carcinoma with normal DRE and PSA levels from 0.1 to 34.9 ng/ml (mean 9.0 ng/ml). Four patients (3%) had stage B carcinoma with an average PSA level of 32.3 ng/ml and less than one lobe indurated on DRE. Six patients (5%) had stage C carcinoma and had an average PSA level of 48.5 ng/ml and less than one lobe indurated on DRE. Ninety-four (78%) patients had stage D carcinoma with an average PSA level of 120 ng/ml and more than one lobe indurated on DRE. While hypoechoic sectors were more than twice as likely as isoechoic sectors of the prostate to contain malignancy on biopsy, nearly 20% of cancers were found in isoechoic sectors. CONCLUSION: Serum PSA is the most accurate of the three diagnostic tests evaluated. The addition of DRE or TRUS improves the detection rate of prostate cancer over PSA alone.

Improvement of health outcomes after continued implementation of a clinical pathway for radical nephrectomy.

The clinical pathway is an important tool for outcome management. We evaluated the overall effects of the continued implementation of a clinical pathway for radical nephrectomy on the length of hospital stay, admission charges, and the quality of medical care. The data obtained from the second-year implementation (group 3) of the clinical pathway were compared with the data from the first-year implementation (group 2) and the year preceding implementation (group 1). Thirty-seven consecutive patients with renal cell carcinoma underwent radical nephrectomy in group 1, 47 in group 2, and 55 in group 3; all were enrolled in this study. The length of hospital stay, average admission charges, and 8 quality indicators were measured in these patients. We also evaluated the variances in the implementation of the clinical pathway. The mean length of stay decreased by 14.0% (P = 0.0048) in group 2, and by 15.8% (P= 0.0014) in group 3, when compared to group 1. The total admission charges significantly decreased by 19.0% (P = 0.001) in group 2, and by 27.9% (P < 0.0001) in group 3, compared to the charges for group 1. A continued decrease in charges for operation and anesthesia, laboratory, pharmacy, and others were found 2 years after implementation of the clinical pathway. Among the 8 quality indicators, 2 were continuously improved in the second-year implementation of the clinical pathway, 2 were improved significantly in the second-year implementation only, and 4 showed no significant change at all. Variances from the clinical pathway decreased significantly after continued implementation. Continued implementation of the clinical pathway for radical nephrectomy can improve a physician's practice continuously by decreasing the length of hospital stay, admission charges, and variances, and by improving quality. However, the improved results after implementation of the clinical pathway should be maintained carefully to assure good health care.

Leiomyoma of the epididymis: case report.

Herein, we report on a rare case of leiomyoma of the epididymis. The case we present involved a 55-year-old patient who had had a painless left scrotal mass for 20 years. The mass was round and elastic and measured about 2 x 2 x 2 cm. We recognized the mass as a benign tumor by scrotal ultrasonography and performed an organ salvage operation for this patient. The final pathologic diagnosis of the mass was leiomyoma. Our report includes a detailed description of the ultrasonographic characteristics of this disease as well as a review of the literature. In general, sharp acoustic shadows with central hypoechoic lesions in heterogenous parenchyma are the distinctive characteristics of leiomyoma of the epididymis. We also discuss the possibility of a testis salvage operation for this type of disease. We conclude that the ultrasonographic characteristics can serve as an important guide for the surgeon to consider an organ salvage operation in cases of a painless scrotal mass.

Subcapsular hematoma of spleen--a complication following extracorporeal shock wave lithotripsy for ureteral calculus.

Splenic trauma with hematoma following extracorporeal shock wave lithotripsy (ESWL) is very rare. We reported a case of subcapsular hematoma of spleen with impending rupture following ESWL for ureteral calculus. This case was noted to have liver cirrhosis and splenomegaly, and received a total of 2000 shock waves under 18 kilovoltage. The subcapsular hematoma occurred 2 months later. Splenectomy was undertaken for a symptomatic huge subcapsular hematoma and thrombocytopenia. We reviewed the literature and concluded that portal hypertension with severe coagulopathy are contraindications for ESWL, even in case with ureteral calculus.

Hematuria from left internal pudendal and obturator arterial bleeding following sexual intercourse.

Bladder tamponade is an uncommon clinical symptom among men who experience suffering related to sexual intercourse. The authors report on a 46-year-old man with this symptom 4-5 years before hospitalization. Angiography confirmed the presence of left pudendal and obturator arterial bleeding, and embolotherapy of the internal pudendal and obturator arteries was performed. There was no mortality, or limb loss or loss of sexual potency at follow-up.