Leiomyosarcoma of the inferior vena cava. Our experience and a review of the literature.

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare malignant tumor, accounting for 2% of all LMSs. Less than 400 cases have been reported in literature. Computed tomography (CT) is the most accurate imaging method in assessing the location of the tumor within the IVC and magnetic resonance imaging (MRI) accurately identifies its extent and the potential for surgical resection. We present the case of a patient with inferior vena cava leiomyosarcoma (IVCL), for whom the pathological diagnosis was different from the initially expected one, the tumor appearance on pre-operative imaging mimicking renal cell carcinoma. The intraoperative difficulty of approaching renal hilum and IVC was a factor suggesting the vascular origin of the tumor, which was confirmed at pathological analysis. The extensive defect in the IVC after tumor excision led to the decision of complete transverse suturing of IVC, as significant collateral venous circulation was already present. Because IVCL is a rare disease, there is scarce data regarding the prognosis and treatment options. Long-term survival depends on the extent of the surgery. The need of vascular reconstruction is not always mandatory. Despite high recurrence rates, no consensus regarding adjuvant treatment exists yet. A multidisciplinary approach including surgical oncologists and vascular surgeons is mandatory to achieve the best patient outcomes. Perioperative planning, coordination and adherence to oncological techniques are critical.

Local staging of prostate cancer with multiparametric-MRI: accuracy and inter-reader agreement.

BACKGROUND: The accuracy of prostate cancer local staging at the time of diagnosis directly influences patient prognosis and treatment. AIM: To evaluate the diagnostic performance and interobserver variability of mp-MRI in local staging of prostate cancer, using the histopathologic findings at prostatectomy as the reference standard. METHODS: Fifty patients (mean age 64.4±7.2) with biopsy confirmed prostate cancer were included in this prospective study. All patients were examined with mp-MRI before radical prostatectomy and images were read by three independent radiologists. Sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), and accuracy rate were calculated and compared for all three readers. Interobserver agreement was evaluated using Kappa Cohen coefficient of agreement. RESULTS: The overall Se, Sp, PPV, NPV and accuracy rates for detecting extraprostatic tumor extension (EPE) ranged between 76.5-94.1%, 45.5-84.9%, 43.8-76.2%, 83.3-96.6% and 58-88%. For evaluation of seminal vesicle invasion (SVI), the overall Se, Sp, PPV, NPV and accuracy rates ranged between 57.1-85.7%, 86.1-97.7%, 40.0-85.7%, 92.5-97.7% and 82-96%, respectively. The overall Kappa Cohen coefficient of agreement varied between 0.349-0.638 for EPE and between 0.507-0.668 for SVI. CONCLUSIONS: Our results showed that 1.5T mp-MRI is a reliable method for local staging of prostate cancer, with good diagnostic performance in detecting EPE and SVI. The overall interobserver agreement rates between readers with the same level of experience in prostate MRI ranged from fair to good in the evaluation of EPE and from moderate to good for the assessment of SVI.

How reliable and useful are angiogenesis blood mediators for prostate cancer diagnosis?

PURPOSE: To evaluate if a blood panel of genes involved in the modulation of the immune system, angiogenesis and tumor development could be used for prostate cancer detection. METHODS: Gene expression profiling of blood samples was assessed with the human angiogenesis RT² Profiler™ pcr array. The study group was divided into training and a testing/validation set. In total, 36 blood samples from 6 heatlhy men, 19 patients with prostate cancer (PCa) and 11 patients with benign prostate pathology (BP) were included in this study. RESULTS: Transcriptional analysis revealed a supervised signature of 28 genes which discriminated the PCa samples from control on the training set (fold regulation [FR] cut off 1.5, p<0.05). This signature was further validated on the testing set. All 28 genes used for this classification were differentially expressed in the new set of 12 PCa samples compared to control but also compared to benign samples (FR cut off 1.5, p<0.05). CONCLUSIONS: Our data could provide new insight into PCa, as a non-invasive predictive tool which along with other factors could improve PCa diagnosis. However, our findings have to be confirmed in a larger cohort of patients before having a clear picture of how this molecular profile will help to increase the accuracy of diagnosis.

CD105 as a tool for assessing microvessel density in renal cell carcinoma.

BACKGROUND: Angiogenesis plays an essential role in both tumor growth and metastasis. CD105 expression was correlated with prognosis in many tumors, but its value in renal cell carcinoma (RCC) is still questionable. MATERIALS AND METHODS: The aim of this study was to evaluate microvessel density (MVD) by using CD105 marker, in 95 cases of renal cell carcinoma. RESULTS: CD105 showed positivity in 93 cases. The mean MVD value was significantly higher in clear cell carcinoma compared to papillary and chromophobe subtypes (P = 0.000). We noticed a significant correlation between MVD and ISUP grade (P = 0.007). The highest MVD value was observed in tumors with ISUP grade 1 and 2, while the lowest MVD value was noted in ISUP grade 3 tumors. A high vessel density was identified in tumors with a low Fuhrman grade, compared to those with a high grade (P = 0.010). MVD value was lower in tumors with a larger diameter, compared to small ones (P = 0.026). CONCLUSION: In conclusion, CD105 expression (MVD) is inversely related to tumor aggressiveness in clear cell RCC and can be used as a favorable prognosis marker. The vascularity differences between histological subtypes of RCCs could be useful for a better selection of patients that may benefit from anti-angiogenic therapies.

MRI-TRUS fusion guided prostate biopsy - initial experience and assessment of the role of contralateral lobe systematic biopsy.

AIMS: To present our initial experience and results of MRI-TRUS fusion guided prostate biopsy and assess the role of contralateral lobe systematic biopsy. MATERIAL AND METHOD: A number of 119 patients with clinical or biochemical suspicion for prostate cancer (PCa) were included. All patients harbored at least one PIRADS score ≥ 3 lesion and underwent MRI-TRUS fusion guided biopsy, as well as a concurrent systematic biopsy. The biopsy was performed by the same operator, using a rigidregistration software system. RESULTS: The mean age of the patients was 62.2 years. The mean pre-biopsy PSA was 9.15 ng/dl. The diagnosis rate of MRI-TRUS fusion guided biopsy was 47% for overall PCa and 29.4% for clinically significant (cs) PCa. A higher PIRADS score was significantly associated with the presence of overall and csPCa. MRI-TRUS fusion guided biopsy had a higher percentage of positive biopsy cores (51% vs 29%), higher likelihood of csPCa (OR 5.36, p=0.008) and upgrading (14.8%) in comparison with systematic biopsy but missed 6.7% csPCa. The contralateral lobe systematic biopsy could have been avoided without losing the PCa diagnosis all patients with PIRADS score 5, both in initial and repeat biopsy setting. Anterior and transitional lesions were more likely to be diagnosed only by targeted cores. CONCLUSION: MRI-TRUS guided prostate biopsy improves the detection of PCa, but systematic biopsy is still essential. In selected cases (PIRADS 5), contralateral lobe systematic biopsy can safely be avoided. Pre-biopsy mpMRI might reduce the number of biopsy sessions in patients with anterior and transitional lesions.

Expression and Distribution of Galectin-3 in Chromophobe and Papillary Carcinomas.

BACKGROUND/AIM: Probably due to their low occurrence, chromophobe and papillary renal cell carcinomas are less well characterized and, currently, there are no reliable prognostic markers for this group of patients. Moreover, the optimal therapy for patients with non-clear renal cell carcinoma (RCC) is unknown yet. Although elevated levels of Galectin-3 (Gal-3) were associated with poor prognosis in conventional RCC, the impact of this protein on carcinogenesis of chromophobe and papillary entities has not been previously described. MATERIALS AND METHODS: Gal-3 expression was investigated in 34 consecutive cases of RCCs, including 19 papillary carcinomas and 15 chromophobe carcinomas. RESULTS: Immunohistochemical analysis of Gal-3 in tumor cells showed 3 patterns of expression: membranous, cytoplasmic and nuclear staining. Most tumors included in our study showed a cytoplasmic expression and it was almost equally distributed between the histologic subtypes. However, only nuclear staining of Gal-3 was associated with both Fuhrman grade and tumor stage (p=0.016 and p=0.032, respectively) in chromophobe subtype. CONCLUSION: Our results indicate that the nuclear expression of Gal-3 has an essential role in the development of chromophobe carcinoma. The association with advanced tumor stage and nuclear grade suggests that this protein is an indicator of aggressiveness in the chromophobe subtype, thus targeting anti-nuclear transport may prove an effective therapy for this particular group of patients.

Spontaneous cholecystocutaneous fistula as a primary manifestation of gallbladder adenocarcinoma associated with gallbladder lithiasis - case report.

Spontaneous cholecystocutaneous fistula (SCF) is a rare complication of neglected calculous biliary disease and also an extremely rare complication of gallbladder neoplasm. This pathology has become even rarer because of prompt diagnosis and expedient surgical intervention for gallstones. So far, there is one published report of a SCF due to gallbladder adenocarcinoma. We present the case of a woman aged 87 years, admitted to the Vth Department of Surgery, Clinical Municipal Hospital of Cluj-Napoca (Romania) for a tumoral mass located in the epigastrium. In the epigastrium, the patient had three skin orifices of about 1-2 mm each, through which purulent secretion occurred. The abdominal ultrasound highlighted a cholecystocutaneous fistula with the presence of a subcutaneous gallstone. Intraoperatively, we found a cholecystocutaneous fistula, a 1 cm subcutaneous gallstone, gallbladder with thickened walls containing a cylinder-shaped gallstone of 5÷3 cm. Fistulectomy, gallstones extraction and cholecystectomy were performed. The histopathological examination highlighted gallbladder adenocarcinoma. In conclusion, SCF can be the first significant manifestation of gallbladder cancer associated with neglected calculous biliary disease.

Investigation of Renal Cell Carcinoma by Contrast-Enhanced Ultrasound- Predictive Value of Time Intensity Curve Analysis in Establishing Local Tumor Invasion and Stage: A Pilot Study.

PURPOSE: Contrast-enhanced ultrasound (CEUS) allows for real-time examination of signal intensity changes in a region of interest (ROI) and quantification of contrast agent kinetics. This study assessed the predictive ability of time-intensity curve (TIC) parameters for local tumor invasion and T stage of renal cell carcinoma (RCC). MATERIALS AND METHODS: Renal tumors in 41 patients were examined by CEUS. Thirty-two met the inclusion criteria, with a total of 33 tumors (27 clear cell, 4 chromophobe, and 2 papillary type I). Nineteen (57.6%) tumors were included in group A (stages pT1 and pT2) and 14 (42.4%) in group B (stage pT3). ROIs were established as: whole tumor (TuW); tumor area with the highest signal intensity (TuMAX) and renal cortex (Ref). The TIC param­eters for each ROI were calculated as below: peak signal intensity, time to peak (TTP), rise time (RT), and mean transit time (MTT). They were analyzed as a whole value for each ROI and as a ratio between the different ROIs. RESULTS: There were significant differences between the tumors invading and not invading the renal sinus fat for TTP (TuW/Ref) [0.98 (0.67-1.25) vs. 1.18 (1.08-1.3), P < .05]. For differentiation between groups A and B, the following ratios were proven as predictors by univariate regression analysis: TTP (TuMAX/TuW); MTT (Tu­MAX/TuW); RT (TuMAX/TuW) (P = .03, P = .01 and P = .02, respectively). The value derived from the Receiver Operating Characteristic (ROC) curve for RT (TuMAX/TuW) was 0.8 with sensitivity = 78.6%, specificity = 89.5%, and cutoff value of > 0.91. CONCLUSION: TIC parameters were predictors of locally noninvasive and invasive RCC.

Retroperitoneal perirenal myxoid liposarcoma.

Liposarcomas are neoplasms of mesodermic origin, are derived from adipose tissue and represent <1% of all malignant tumours. Primary liposarcomas of the kidney are very rare. Here, we present the cases of two patients diagnosed with retroperitoneal perirenal myxoid liposarcoma. The patients were diagnosed via imaging, which in both cases revealed a huge right retroperitoneal tumour mass compressing the abdominal organs and large blood vessels. Surgical intervention consisting of en bloc resection of the tumour and the right kidney was performed using a transperitoneal approach. Three years after the surgery, both patients presented local recurrence, for which they underwent chemotherapy. Liposarcomas with renal origin are rare clinical entities with a high rate of malignancy and a poor prognosis. Because the use of chemotherapy and radiotherapy in the treatment of such liposarcomas is controversial, the treatment of choice is wide surgical resection with clean margins.

Management of renal extraskeletal mesenchymal chondrosarcoma.

BACKGROUND: Primary mesenchymal chondrosarcoma of the kidney is an extremely rare malignant tumor. To our best knowledge, only 9 such cases have been reported so far. CASE PRESENTATION: In the current paper, we present the case of a 67 year-old patient with recurrent left lumbar pain, increased fatigability and intermittent macroscopic hematuria. He underwent a surgical resection of the left kidney and left hemicolon.The pathological diagnosis was primary extraskeletal renal mesenchymal chondrosarcoma. Overall survival was 9 months, with pulmonary metastasis and local recurrence at 6 months. The management of the patient is described, from the initial differential diagnosis, after the first clinical examination to the surgical resection, with a special emphasis on the surgical procedures that were carried out. CONCLUSION: Extraskeletal chondrosarcoma of primary origin in the kidney are extremely rare tumors with a highly malignant potential and very poor prognosis. Because the role of chemotherapy or radiation therapy has not been evaluated properly yet, we underline the importance of surgery in the management of such cases as the main and best approach to achieve clinical remission and long-term survival, provided the patient is referred to a surgical consult in time.

Identifying molecular features for prostate cancer with Gleason 7 based on microarray gene expression profiles.

Prostate cancer represents the first leading cause of cancer among western male population, with different clinical behavior ranging from indolent to metastatic disease. Although many molecules and deregulated pathways are known, the molecular mechanisms involved in the development of prostate cancer are not fully understood. The aim of this study was to explore the molecular variation underlying the prostate cancer, based on microarray analysis and bioinformatics approaches. Normal and prostate cancer tissues were collected by macrodissection from prostatectomy pieces. All prostate cancer specimens used in our study were Gleason score 7. Gene expression microarray (Agilent Technologies) was used for Whole Human Genome evaluation. The bioinformatics and functional analysis were based on Limma and Ingenuity software. The microarray analysis identified 1119 differentially expressed genes between prostate cancer and normal prostate, which were up- or down-regulated at least 2-fold. P-values were adjusted for multiple testing using Benjamini-Hochberg method with a false discovery rate of 0.01. These genes were analyzed with Ingenuity Pathway Analysis software and were established 23 genetic networks. Our microarray results provide new information regarding the molecular networks in prostate cancer stratified as Gleason 7. These data highlighted gene expression profiles for better understanding of prostate cancer progression.

Real-time sonoelastography in the diagnosis of prostate cancer.

AIMS: Sonoelastography (SEG) is a noninvasive ultrasound (US) method able to differentiate tissues according to their stiffness. Our objective was to establish whether transrectal (TR) SEG may improve prostate cancer detection, alone or associated with other US methods. PATIENTS AND METHODS: We analyzed the data of 65 patients, mean age 68 years (49 - 81 years), examined March 2009-September 2010. The patients had at least one of the following malignancy suspicion criteria: PSA > 4 ng /ml (minimum 2 determinations), nodule(s) at digital rectal examination (DRE +) or previous gray scale TRUS positive appearance. All patients underwent TRUS, Doppler-US and SEG in the same session, followed by systematic prostate biopsies (6-12 cores). Histopathology and imaging findings were correlated. RESULTS: Twenty-eight out of 65 patients (43%) were diagnosed with prostate cancer. Overall, SEG had a sensitivity of 67.85%, specificity 62.16%, positive predictive value 57.57% and negative predictive value 71.85%. However, SEG diagnostic reliability appeared to be higher for subgroups of patients having PSA >10 ng / ml, lower number of fragments collected by PBP (6 vs. 10-12 cores) and age > 70 years. CONCLUSION: SEG appears to be useful in the diagnosis of prostate cancer as it may increase the diagnosis accuracy in specific target groups.

Hepatic and skin metastases after laparoscopic radical prostatectomy for prostate cancer.

Between 2004 and 2006, 50 radical prostatectomies were performed in our department, 46 of them through a laparoscopic approach addressed to early stage cancer (T1a,b,c and T2a,b,c N0 M0). We present the case of a 63 year old patient, who was initially diagnosed with prostate cancer in T1bN0M0 stage, Gleason score 8 and later presented atypical hepatic and trocar site metastases. This particular evolution of the case can be explained by the high value of the Gleason score and by the extension into microvessels observed on the sample prelevated by prostatectomy. The rarity of this atypical metastases and its association, the diagnostic and therapy problems are the reasons for the detailed presentation of this case.