A novel case of concurrent renal tumors: chromophobe renal cell carcinoma and carcinoid tumor of the kidney with brief review of renal neuroendocrine tumors.

Renal cell carcinoma of chromophobe type is a malignant neoplasm with characteristic large cells that exhibit prominent cell membranes. Primary renal carcinoid tumors are rare tumors with the histological appearance similar to well-differentiated neuroendocrine tumors at other sites. Chromophobe renal cell carcinoma with neuroendocrine differentiation is exceedingly rare. The authors describe a case of a chromophobe renal cell carcinoma and carcinoid tumor of the kidney presenting as distinct masses in the same kidney in a 34-year-old male. The histologic and immunohistochemical features of both the tumors were characteristic with no overlapping features. The carcinoid tumor presented at a higher stage with nodal metastasis. To the best of the authors' knowledge, this is the first case of 2 morphologically distinct tumors, one chromophobe renal cell carcinoma and the other primary carcinoid tumor in the same kidney.

Long-term follow-up of men with isolated high-grade prostatic intra-epithelial neoplasia followed by serial delayed interval biopsy.

OBJECTIVES: To analyze the outcomes of serial delayed interval biopsy (DIBx) in men with isolated high-grade prostatic intraepithelial neoplasia (HGPIN). The natural history of isolated HGPIN is poorly defined. Since January 2000, we have monitored men with isolated HGPIN using DIBx every 3 years, regardless of the change in prostate-specific antigen (PSA) level. METHODS: The institutional biopsy records from 1996 onward were reviewed to identify the men with isolated HGPIN found on 12-core needle biopsy specimens who had undergone a minimum of 1 DIBx in our follow-up strategy. Patient age, biopsy and prostatectomy pathologic outcomes, and longitudinal PSA measurements were recorded. RESULTS: A total of 112 men had undergone a first DIBx and 47 had undergone a second DIBx at the last follow-up examination at a mean of 34.4 and 66.2 months after the HGPIN diagnosis, respectively. Prostate cancer was found in 25 (22.3%) of 112 men and 11 (23.4%) of 47 men at DIBx-1 and DIBx-2, respectively. The PSA velocity was not predictive of cancer during short-term follow-up. Of the men diagnosed with cancer, 63.6% had a Gleason score of ≥7, and 9 (81.8%) of 11 men had clinically significant disease (Gleason score of ≥7 and/or >5% cancer volume) at surgery. All cancers were organ confined at and surgery. CONCLUSIONS: Men with isolated HGPIN have a continued risk of developing prostate cancer during long-term follow-up, regardless of the changes in the serum PSA level. Collectively, the relatively high likelihood of organ confinement and clinically significant cancer suggest empiric DIBx every 2-3 years could be a valuable tool in the follow-up of men with isolated HGPIN found by extended core biopsy.

Adrenocortical carcinosarcoma: a case report and review of the literature.

Adrenocortical carcinosarcoma is an extremely rare and aggressive variant of adrenocortical carcinoma characterized by the presence of both carcinomatous and sarcomatous components, with the latter often showing heterologous differentiation. Due to the rarity and unusual histology, it may pose a diagnostic challenge. In order to increase awareness and identify potential diagnostic pitfalls, we report the ninth case of non-functioning adrenocortical carcinosarcoma in a 45-year-old man who presented with worsening epigastric pain and a left large retroperitoneal mass in close proximity to the body/tail of pancreas and third portion of the duodenum with displacement of the kidney without parenchymal invasion and multiple liver nodules detected by computed tomographic scan. On en bloc resection, the tumor grossly did not involve the pancreas, kidney or colon. Histologically, the tumor was composed of two distinct components - an epithelioid component with granular cytoplasm that stained for synaptophysin, Melan-A, calretinin, and vimentin compatible with adrenocortical differentiation, and a pleomorphic to spindled component that was positive for desmin and myogenin, compatible with rhabdomyosarcomatous differentiation. A wedge biopsy of a liver nodule showed morphologic features similar to the epithelial component of the primary tumor. The patient died three months after surgery due to locoregional and distant recurrence. Adrenocortical carcinosarcoma is a rare malignancy that adds to the differential diagnostic considerations for a retroperitoneal epithelioid malignancy. Awareness of this as a possibility will help in distinguishing this tumor from other carcinomas, melanomas, and true sarcomas.

Health related quality of life for men treated for localized prostate cancer with long-term followup.

PURPOSE: Men who undergo primary treatment for prostate cancer can expect changes in health related quality of life. Long-term changes after treatment are not yet fully understood. We characterized health related quality of life evolution from baseline to 4 years after treatment. MATERIALS AND METHODS: We identified 1,269 men in CaPSURE who underwent primary treatment for clinically localized prostate cancer and completed followup health related quality of life questionnaires for at least 4 years. The men underwent radical prostatectomy, external beam radiotherapy, brachytherapy, combined external beam radiotherapy/brachytherapy or androgen deprivation therapy. Health related quality of life was measured using patient reported questionnaires. Effects of select covariates on quality of life were measured with a multivariate mixed model. RESULTS: Age at diagnosis, time from treatment and primary treatment were significant predictors of health related quality of life in all domains (p <0.05) except primary treatment on sexual bother. Men who underwent radical prostatectomy experienced the most pronounced worsening urinary function but also had the greatest recovery. All treatments worsened urinary bother, and sexual function and bother. All forms of radiotherapy moderately worsened bowel function and bother after treatment but eventual recovery to baseline was noted. CONCLUSIONS: Age at diagnosis, time from treatment and primary treatment type affect health related quality of life. Treatment has a greater impact on disease specific than general health related quality of life. All treatments adversely affect urinary and sexual function. Most adverse changes develop immediately after treatment. Recovery occurs mostly within 2 years after treatment with little change beyond 3 years.

Clinical outcomes and recurrence predictors of lymph node positive urothelial cancer after cystectomy.

PURPOSE: Lymph node metastasis in patients who undergo radical cystectomy for bladder transitional cell carcinoma is considered a poor prognostic factor. However, patients with minimal lymph node involvement likely have a better outcome than those with extensive disease. We examined outcomes in patients with low volume lymph node metastasis and identified variables associated with disease recurrence. MATERIALS AND METHODS: Our institution maintains a database of 1,600 patients with bladder transitional carcinoma who underwent radical cystectomy from 1971 to 2005 with intent to cure. All patients with low volume lymph node metastasis, defined as 1 or 2 positive lymph nodes, without concomitant distant metastasis were included in study. RESULTS: A total of 181 patients were identified. Median followup was 12.8 years, during which 96 patients experienced recurrence. Estimated 5 and 10-year recurrence-free survival was 43.8% and 40.9%, respectively. Multivariate analysis indicated that pathological stage/subgroup (RR 1.733, p = 0.015), lymph node density (RR 1.935, p = 0.014) and adjuvant chemotherapy (RR 0.538, p = 0.004) were significant independent predictors of recurrence-free survival. CONCLUSIONS: A considerable proportion of patients with low volume lymph node metastasis in our cohort remained free of recurrence during followup. Extravesical tumor extension and lymph node density greater than 4% were associated with a higher recurrence risk and adjuvant chemotherapy was associated with a lower risk. Although some patients with low volume lymph node metastasis may be cured by surgery alone, these data support adjuvant chemotherapy in these patients.

Predictors of intravesical therapy for nonmuscle invasive bladder cancer: results from the surveillance, epidemiology and end results program 2003 patterns of care project.

PURPOSE: In response to variations in cancer care organizations have developed clinical guidelines. In the case of nonmuscle invasive bladder cancer, also known as superficial bladder cancer, 2 similar sets of guidelines were released in the late 1990s that provide care recommendations. We examined patterns of intravesical therapy use in nonmuscle invasive bladder cancer in 2003 to determine whether disparities remained in the quality of cancer care. MATERIALS AND METHODS: Data from the SEER (Surveillance, Epidemiology and End Results) Program 2003 Bladder Cancer Patterns of Care project were used. Subjects newly diagnosed with nonmuscle invasive bladder cancer in 2003 were included. Clinical and sociodemographic data were obtained from the SEER Program and a detailed medical record review. Statistical analysis was performed to identify independent predictors of intravesical therapy in the entire cohort and in a subset of patients at high risk. RESULTS: A total of 685 patients were included in the study, of whom 216 (31.5%) received intravesical therapy. In addition to higher tumor stage and grade, intravesical therapy was independently associated with race/ethnicity and geographic region. Of the subset of 350 patients at high risk 42% received intravesical therapy. Stage, grade, race/ethnicity and geographic region were independently associated with intravesical therapy in this subcohort. CONCLUSIONS: These data suggest the underuse of intravesical therapy even in patients with high risk nonmuscle invasive bladder cancer as well as disparities in the quality of care. Barriers to using this cancer treatment must be identified, particularly in individuals at higher risk, and providers must become more aware of existing clinical guidelines.

Internet health resources and the cancer patient.

The last decade has witnessed an explosion of online information regarding cancer and healthcare. Accompanying this has been a large body of research analyzing the quality of this information, how patients perceive these data and how this affects the doctor-patient relationship. This report reviews this literature, summarizing the current state of internet health resources available to the cancer patient and identifying areas for future research. Studies indicate that there are considerable internet resources available to cancer patients and that patients are using these resources as secondary information sources. Specifically, studies indicate that 16-64% of patients are using the internet to obtain health information. For the most part, patients perceive the online information to be reliable but maintain a healthy degree of skepticism. Studies objectively evaluating cancer information on the internet indicate that there is reasonable quality, although the language level of many sites is higher than that of the average American, which may limit the utility of the websites. Finally, while there is widespread internet use by physicians, healthcare providers are skeptical of their patients' ability to use the internet and may even be somewhat threatened by it. In summary, while there is a fairly large literature on internet resources available to the cancer patient, more research is needed. Specifically, it is important to better understand how patients access health information online and their associated preferences so that we can improve cancer patient's access to high quality health information on the internet to facilitate decision-making and health outcomes.

Open radical cystectomy with lymphadenectomy remains the treatment of choice for invasive bladder cancer.

PURPOSE OF REVIEW: Radical cystectomy with an appropriate lymph node dissection and an appropriate form of urinary diversion is the standard treatment for muscle-invasive transitional cell carcinoma of the bladder. Optimal outcomes following radical cystectomy require an extended lymph node dissection, negative surgical margins, and a continent urinary diversion. There has been an increasing number of reports describing initial experiences with laparoscopic radical cystectomy. RECENT FINDINGS: Intermediate and long-term oncologic outcomes with laparoscopic radical cystectomy remain undefined, and appropriate lymph node dissections laparoscopically have not been uniformly performed. Furthermore, the long-term functional outcomes associated with laparoscopically performed urinary diversions also remain undefined. There appears to be a recent trend toward performing the urinary diversion portion of the procedure extracorporeally, after laparoscopic removal of the bladder. Some studies suggest a decrease in postoperative analgesic requirements and quicker recovery of bowel function in those undergoing laparoscopic radical cystectomy, but these observations have not been corroborated by others. SUMMARY: In the absence of long-term functional and oncologic outcome data, laparoscopic radical cystectomy should be considered an investigative technique, and potential candidates for this operation should be appropriately counseled.

Preoperative renal tumor evaluation by three-dimensional magnetic resonance imaging: Staging and detection of multifocality.

OBJECTIVES: To evaluate, retrospectively, the staging accuracy of three-dimensional magnetic resonance imaging (3D-MRI) in our institution as a prelude to a prospective comparison of 3D-MRI and 3D computed tomography (CT) for preoperative planning of partial nephrectomy. In recent years, the use of 3D-CT for preoperative evaluation and surgical planning in patients undergoing nephron-sparing surgery has gained considerable popularity. METHODS: The images of 26 consecutive patients evaluated by 3D-MRI as part of the preoperative imaging studies for renal tumor were evaluated retrospectively and compared with the surgical pathologic findings to evaluate the ability of 3D-MRI to predict tumor multifocality, tumor stage, collecting system invasion, and venous invasion. RESULTS: 3D-MRI accurately predicted tumor multifocality in 1 of 2 cases. Imaging identified five of seven multifocal lesions. Two subcentimeter lesions were missed. Preoperative staging was correct in 29 of 30 lesions (97% accuracy). One T3b tumor was incorrectly staged as T2. Venous invasion was identified in 2 of 3 cases (67% sensitivity), but no false-positive results were seen. 3D-MRI had 100% sensitivity and 88% specificity in the prediction of collecting system invasion. CONCLUSIONS: The staging accuracy of 3D-MRI appears to be quite good. Given the accuracy of this technique, along with the popularity of 3D imaging before renal surgery, these results provide the impetus for a future study directly comparing 3D-CT with 3D-MRI in the capacity of surgical preoperative planning.