Managing the unexpected: Carcinosarcoma of the kidney parenchyma A case with the longest follow-up.

INTRODUCTION: We present the management of the second reported case of carcinosarcoma of the kidney parenchyma with malignant degeneration of both epithelial and mesenchymal components. CASE REPORT: A 36-year-old woman came to our attention for an incidental sonographic finding of a lesion in the lower pole of the left kidney. A contrasted computed tomography scan confirmed the presence of a 50 × 52 mm2 contrasted lesion in the left lower kidney pole. The patient underwent a challenging laparoscopic left partial nephrectomy and para-aortic lymphadenectomy. The histological examination led to the diagnosis of a carcinosarcoma of the kidney parenchyma with malignant degeneration of both epithelial and mesenchymal components. The patient underwent adjuvant chemotherapy with paclitaxel at 175 mg/m2 plus carboplatin area under the curve 6 intravenously for six cycles. At a follow-up of 42 months, the patient is alive and does not show any local recurrences or distant metastases. CONCLUSION: A multi-disciplinary therapeutic approach, combined with an adequate doctor-patient relationship and a close and detailed follow-up, is of fundamental importance in obtaining good outcomes in such rare and challenging cases.

Late urinary bladder metastasis from breast cancer.

INTRODUCTION: Breast cancer (BrC) is the most common non-dermatologic cancer in women. It frequently metastasizes to lung, liver and bone, while the urinary bladder is considered as an unusual site for BrC metastases. MATERIALS AND METHODS: Four years after her first oncologic surgical approach, a known BrC patient complained of a left flank pain, dysuria and urgency. Computed tomography (CT scan) imaging showed an irregular thickening of the left bladder wall and bilateral hydronephrosis. RESULTS: A bladder metastases from BrC was diagnosed based on a histological examination of a transurethral resection of the bladder (TURB-T) specimen. CONCLUSIONS: In patients with a history of BrC, urinary bladder screening is not needful. However, if low urinary symptoms persist, an evaluation of the bladder should be considered to rule out metastatic involvement.

Urinary bladder xanthoma: Two case reports and a review of the literature.

OBJECTIVE: We present two rare cases ofbladder xanthomata associated with transitional cell carcinoma. METHOD AND RESULTS: Cases description and selectionof related pictures. Review of the existing literature. CONCLUSIONS: Xanthomata are non-neoplastic lesionsconsisting of group of foamy lipidstoring histiocytes in thedermis of skin or in the lamina propria of mucosa. Urinarybladder is an uncommon localization for these lesions andtheir etiology isn't still well understood, being variably associatedwith abnormalities of lipid metabolism. Althoughsometimes they are described in association with urothelialneoplasms, they were not believed to have any biologicalneoplastic potential and so they are treated consequently.

OBJETIVO: Presentamos dos raros casos de Xantoma vesical asociado con carcinoma de células transicionales.MÉTODOS Y RESULTADOS: Descripción de los casos y selección de imágenes relacionadas. Revisión de la bibliografía existente. CONCLUSIONES: Los xantomas son lesiones no neoplásicas constituidas por grupos de histiocitos espumosos almacenadores de lípidos en la dermis cutánea o en la lámina propia de la mucosa. La vejiga urinaria es una localización rara de estas lesiones y su etiología no se entiende bien todavía, asociándose variablemente con anomalías del metabolismo lipídico. Aunque a veces se describen en asociación con neoplasias uroteliales, no se piensa que tengan ningún potencial neoplásico y consecuentemente así se tratan.

Urinary bladder xanthoma: two case reports and a review of the literature / Xantoma vesical: Presentación de dos casos y revisión bibliográfica

OBJECTIVE: We present two rare cases of bladder xanthomata associated with transitional cell carcinoma. Method and results: Cases description and selection of related pictures. Review of the existing literature. CONCLUSIONS: Xanthomata are non-neoplastic lesions consisting of group of foamy lipidstoring histiocytes in the dermis of skin or in the lamina propria of mucosa. Urinary bladder is an uncommon localization for these lesions and their etiology isn't still well understood, being variably associated with abnormalities of lipid metabolism. Although sometimes they are described in association with urothelial neoplasms, they were not believed to have any biological neoplastic potential and so they are treated consequently

OBJETIVO: Presentamos dos raros casos de Xantoma vesical asociado con carcinoma de células transicionales. MÉTODOS Y RESULTADOS: Descripción de los casos y selección de imágenes relacionadas. Revisión de la bibliografía existente. CONCLUSIONES: Los xantomas son lesiones no neoplásicas constituidas por grupos de histiocitos espumosos almacenadores de lípidos en la dermis cutánea o en la lámina propia de la mucosa. La vejiga urinaria es una localización rara de estas lesiones y su etiología no se entiende bien todavía, asociándose variablemente con anomalías del metabolismo lipídico. Aunque a veces se describen en asociación con neoplasias uroteliales, no se piensa que tengan ningún potencial neoplásico y consecuentemente así se tratan

Multiple, Synchronous Lesions of Differing Histology Within the Same Testis: Ultrasonographic and Pathologic Correlations.

OBJECTIVE: To describe ultrasound (US) and pathologic findings in 11 patients with multiple, synchronous lesions of different histology within the same testis. MATERIALS AND METHODS: We reviewed US and pathologic findings in 11 patients with multiple, synchronous lesions of different histology within the same testis. Lesions were classified as separate or adjacent one to another and attempt was made to predict tumor type on their US textures. Pathologic review assessed presence of normal tissue between adjacent lesions and of Germ Cell Neoplasia In Situ in surrounding parenchyma. Nine cases were from files specifically dedicated to testicular tumors and estimated prevalence was calculated. RESULTS: Two nodules were seen in nine patients and 3 in remaining two. Nine had tumors of different histology; two had one malignancy and one focal benign lesion. Germ Cell Neoplasia In Situ was seen in 7/11 cases. In dedicated archives, these lesions had 1.83% prevalence. CONCLUSION: Multiple focal lesions identified at imaging within the testis are not always of the same histology. This can be suspected in some cases basing on US texture. Recognition that lesions are multiple and an indication of their locations within the testis is the most important role of imaging and may help pathologists correctly sample the specimen to establish nature of each of them. Presence of multiple lesions is regarded as a contraindication to testicular sparing surgery. In two of our patients, one lesion was benign. Then, when the procedure is indicated all lesions have to be sampled and assessed by pathologists before deciding between conservative or radical technique.

Leiomyoma of the deferens: a curious and extremely rare disease.

INTRODUCTION: Leiomyomas are rare benign tumors that can occur in the male urinary tract. We present a unique case of leiomyoma of the vas deferens. CASE DESCRIPTION: We present the clinical case of a 69-year-old patient with a suspected bulk close to the right epididymis, which turned out to be a leiomyoma of the vas deferens. To our knowledge, it is the fourth case in literature. CONCLUSIONS: A proper identification and the knowledge of this pathology, even if it is a very unusual event, is necessary to avoid a surgical over treatment and preserve the testicle, by removing only the tumor.

Zinner Syndrome: A Diagnostic Challenge. The Aid of Morphology, Embryology, and Immunohistochemistry.

We investigate a patient with right kidney agenesis. Imaging showed the presence of a cystic mass dislocating the bladder. The specimen showed three formations: a kidney remnant, a ureter with blind-ending branch, and a cyst, from which departed another tubular structure, considered the deferential duct. The specimen was sampled. The supposed kidney was formed by cystic structures. Examination of the tubular structures disclosed smooth muscle fibers with no lumen, whereas the cyst was surrounded by fibrous and hemorrhagic walls. Collaboration among specialists allowed the diagnosis of Zinner syndrome, a congenital malformation due to an abnormal development of the Wolffian duct.

Verruciform xanthoma of the penis: A rare benign lesion that simulates carcinoma.

Verruciform xanthoma is a rare and benign condition predominantly affecting the oral cavity, but also skin and female anogenital mucosa. It can be flat, papular-warty or crateriform-cystic. Furthermore it can simulate HPV viral lesion such as condyloma and malignant neoplasia such as verrucous squamous cell carcinoma. An accurate diagnosis is important to avoid overtreatment, considering it is a benign lesion that does not require any radical treatment. We present an extremely rare case of a 64 year-old man with a small, slighty raised, gray reddish-dotted lesion on the left portion of the ventral side of his glans.

Renal Leiomyosarcoma. A Report of Two Cases.

BACKGROUND: Leiomyosarcoma represents a rather uncommon malignancy, and reports of cases characterized by a renal genesis are particularly rare. CASES: We describe 2 cases of leiomyosarcoma of the kidney, in a 63-year-old woman and in a 53-year-old man, respectively. Both tumors share a common immunohistochemical profile with a strong positivity for smooth muscle actin, a focal positivity for desmin, and negativity for cytokeratins and other markers. CONCLUSION: We provide a comparison between our findings and the data available in the literature, and we note an interesting relatively long survival in our patients (10 months for the first case and 20 months for the second case).

Multifocal blue nevus of the prostate: a case report.

BACKGROUND: Blue nevus of the prostate is rare and is most commonly discovered incidentally in patients presenting with classic symptoms of prostatic hyperplasia. Only 32 cases have been reported to date in the literature. We describe the first case of multifocal blue nevus of the prostate gland. CASE: A 69-year-old man presented with obstructive urinary symptoms. The preoperative clinical and radiological fndings had shown a massive increase in the volume of the prostate. Suprapubic prostatectomy was performed with good postoperative course. The histopathological examination disclosed benign hyperplasia with large areas characterized by abundant fibromuscular component. In the context of this hyperplasia were observed a dozen foci of pigmented cells measuring 0.1-1 cm in diameter. Histochemical and immunohistochemical stains confirmed the pigment as melanin. CONCLUSION: A review of the literature shows that the blue nevus of the prostate is an incidental finding and is most often associated with a benign disease of the prostate, as indeed occurred in our case. All the cases reported are monofocal. Ours is the first reported multifocal case and, as the material has not been fully sampled, consists of at least 12 different outbreaks of varying sizes. Even in our case blue nevus was asymptomatic, and the patient showed no symptoms related to the same blue nevus.

Paraganglioma of the urinary bladder: a challenging diagnosis in transurethral resection specimens: a case report.

BACKGROUND: Urinary bladder paraganglioma is a rare neoplasm that originates from embryonic rests of chromaffin cells in the sympathetic plexus of the detrusor muscle, and which occasionally can be observed in transurethral resection specimens. Artifactual changes due to the procedure may frequently simulate an advanced urothelial carcinoma. CASE: A 65-year-old woman presented with episodic macroscopic hematuria. No symptoms of hyperadrenergic stimulation were referred. Cystoscopic examination revealed a protruding mass on the left side of the bladder. Transurethral resection (TUR) was performed, and histological examination revealed a tissue organized in solid nests delineated by delicate fibrovascular septa. There were artifactual changes that consisted of cautery effect and absence of orientation of the fragments. The tumor infiltrated the muscle layer and part of the muscularis mucosae of the bladder. No necrosis or mitoses were observed. On immunohistochemical staining, the tumor cells were negative for epithelial membrane antigen, cytokeratin 7, and carcinoembryonic antigen and positive for chromogranin A, NSE, and PGP9.5. Immunohistochemistry for S-100 highlighted sustentacular cells. CONCLUSION: It is essential to consider the diagnosis of urinary bladder paraganglioma on TUR specimens in order to avoid inappropriate treatment.

Myxoid liposarcoma of the spermatic cord: US and MR imaging findings.

We report a patient with myxoid liposarcoma of the spermatic cord in whom combined use of both ultrasound (US) and MRI helped to suggest the diagnosis. The lesion was solid at US and vascularized at color Doppler. T1-weighted MRI did not show fat within it; on T2-weighted images it had high signal intensity, with a cyst-like appearance. It is known that fat-poor myxoid liposarcomas with high water content may mimic a cystic lesion on non-contrast-enhanced MR; then, a combination of MRI findings, suggesting a cyst, and of US findings, showing the mass was actually solid and vascularized, allowed preoperatively the diagnosis of fat-poor myxoid liposarcoma.

Interstitial cystitis with plasma cell bladder infiltration: case report and literature review.

We report the case of a 76 ys-old woman with overactive bladder syndrome, determined by an histological exam of interstitial cystitis with plasma cell infiltration. To the best of our knowledge, in literature only a similar case has been described. The patient has been treated with corticosteroid therapy allowing a transitory benefit; despite this fact, after side effects have been shown, this therapy has been interrupted leading to the worsening of the previous sintomatology. Therefore the patient has undergone to radical cystectomy with orthotopic ileal neobladder. The phlogistic infiltration of the bladder wall is represented by the plasma cells for over 90% of the whole population. In addition, blood specimen was positive for perinuclear antineutrophil cytoplasmic antibodies (p-ANCA). All these elements could hint at a chronic cystitis due to autoimmune aetiology.

Synchronous parenchymal renal tumors of different histology in the same kidney.

BACKGROUND: Synchronous primary cortical tumors of different histology in the same kidney are rare. Preoperative awareness of this coexistence is important, since it can help in planning the surgical approach. PURPOSE: To describe the imaging findings observed in five patients with two parenchymal malignant tumors of different histology in the same kidney. MATERIAL AND METHODS: We reviewed the pathology reports of 381 patients operated for renal tumors from January 2000 to March 2007. The medical records of all patients with multiple, synchronous, primary lesions of different histology in the same kidney were reviewed with special attention to imaging findings and indications on the nature of the disease process. Computed tomography (CT) examinations were retrospectively evaluated for tumor detection, size, location, and enhancement pattern. RESULTS: We found seven patients with synchronous tumors of different histology in the same kidney (1.8%). Among these, five (1.3%) had two malignancies of different subtypes and represent our study group. Four had preoperative ultrasound; all had CT. Imaging allowed identification of multifocality in 4/5 cases and, in 3/4 patients with visible double tumors, recognition of differences in lesion appearance. In only one patient did the two tumors have similar enhancement patterns. CONCLUSION: It is possible to suspect preoperatively the presence of tumors of different histologic subtypes within the same kidney. Imaging findings may provide information regarding the presence of lesions with different aggressiveness within the kidney, which may be helpful in therapeutic planning.

Bladder cell culture on small intestinal submucosa as bioscaffold: experimental study on engineered urothelial grafts.

OBJECTIVES: To investigate the feasibility to perform primary urothelial cell culture using porcine small intestinal submucosa as a delivery scaffold both in vitro and after in vivo implantation in a rabbit model. MATERIALS AND METHODS: Bladder mucosa samples were aseptically obtained from a group of eight male rabbits. The mucosa was cut into fragments and placed on small intestinal submucosa matrices for selective urothelial cell culture. After complete in vitro epithelization the matrices were shaped into tubes and placed in the subcutaneous tissue and subdartos of donor rabbits. The pattern of cell growth and delivery was evaluated on retrieved grafts using histology and immunostaining at the end of the in vitro phase; then 5, 10 and 20 days after implantation. RESULTS: Histological and immunohistochemical analysis of the in vitro primary culture showed the acellular matrices covered with a thin uninterrupted monolayer of urothelial cells. The implants examined on the day 5 maintained the epithelial configuration of the cultured grafts in all samples retrieved. On the day 10 the urothelium showed increased thickness taking on a bilayer configuration. On day 20, all grafts presented the transitional cells arranged in a double layer closely resembling the natural urothelium. The immunostaining pattern displayed the maintaining of urothelial cell phenotype. No differences in epithelium growth and delivery were noted between the two sites of implantation. Five days after implantation, the histological analysis of small intestinal submucosa showed a medium degree tissue reaction with the presence of acute inflammatory cells. Angiogenesis was demonstrated by the development of several new vessels inside the matrix. After twenty days, small intestinal submucosa was gradually replaced with host tissue. CONCLUSION: The small intestinal submucosa proved to function as a means of delivering of autologous urothelial cells cultured in vitro. After ectopic in vivo implantation the bioscaffold maintained viability and growth of the surrounding cells until its degradation.

Autoimmune hepatitis revealed by atorvastatin.

Cases of acute hepatitis induced by statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) have been reported. A 65-year-old woman was admitted to our hospital because of fatigue, jaundice and altered liver function tests while on treatment with atorvastatin. On the basis of clinical, serological and histological findings, a score leading to a diagnosis of autoimmune hepatitis was reached. We suggest that atorvastatin may have revealed an underlying autoimmune hepatitis.