Tumor de Brenner maligno y embarazo. Caso clínico: revisión de la bibliografía / Malignant Brenner tumor and pregnancy. Case report: Literature review

Resumen ANTECEDENTES: La asociación del tumor de Brenner con el embarazo es excepcional: solo hay cuatro casos reportados, ninguno maligno. CASO CLÍNICO: Paciente de 33 años, con antecedente de un embarazo que finalizó mediante parto y sin contratiempos, sin antecedentes médico-quirúrgicos de interés. En la ecografía de la décima segunda semana se registró una imagen sonoluscente de paredes lisas, de 41 mm, dependiente del ovario izquierdo. Durante la cesárea se practicó la tumorectomía. El estudio histológico describió una neoplasia epitelial de células transicionales, con áreas benignas, proliferativas e infiltrativas, compatible con un tumor de Brenner maligno. Se trató con cirugía radical de cáncer de ovario y quimioterapia coadyuvante. CONCLUSIONES: Es importante tener en mente al tumor de Brenner maligno como diagnóstico de exclusión ante tumoraciones de rápido y gran crecimiento durante el embarazo. En todas las ecografías de seguimiento del embarazo es indispensable valorar los anejos.

Abstract BACKGROUND: The association between Brenner tumor and pregnancy is extremely rare. Only four well-documented cases of benign Brenner tumor during pregnancy have been reported but nonmalignant. CLINICAL CASE: A 33-year-old female patient, with a history of a pregnancy that ended in delivery and without setbacks, with no medical or surgical history of interest. In the ultrasound scan of the twelfth week, a 41 mm smooth-walled sonoluscent image was recorded in the left ovary. Lumpectomy was performed during cesarean section. Histological study described a transitional cell epithelial neoplasm, with benign, proliferative and infiltrative areas, compatible with a malignant Brenner tumor. She was treated with radical ovarian cancer surgery and adjuvant chemotherapy. CONCLUSION: It is important to keep malignant Brenner's tumor in mind as a diagnosis of exclusion in the presence of rapidly and rapidly growing tumors during pregnancy. It is very important to evaluate the appendages in all follow-up ultrasounds during pregnancy.

[Local and systhemic immunotherapy for bladder cáncer: from bench to bedside.] / Inmunoterapia local y sistémica en cáncer de vejiga: bases moleculares y traslación clínica.

Therapeutic approaches for treatment of urothelial transitional cell carcinoma based on immune system modulation, as well as the contribution of intravesica Bacillus de Calmette-Guérin (BCG) and the recentin corporation of checkpoint inhibitors had found irrefutable proofs of concept for the indication of antitumoral immunontherapy in such tumors. Its extension and development at the present time covers all the locations of the wide spectrum of presentation and evolution of these tumors. Nowadays, apart for the low grade non muscle-invasive tumors, we are facingan unpredictable development of antitumoral immunotherapy in bladder cancer not only as an option in the primary treatment, but also in other scenarios such asnon-responders when it comes to BCG, or the situation of ineligibility for systemic chemotherapy indication. The main objective of this review article is trying to translate the current basic mechanisms involved in different phases of transitional cell carcinomas antitumoral response, regardless of whether they are muscle-invasive or not, and to establish the rationale for their therapeutic intravesical or systemic administration. The role of the interactions established between urothelial tumor cells and the cellular and molecular elements of the immune system of patients is described, incorporating the relevant and recent advances in immunobiology and the molecular characterization of these tumors thatwill undoubtedly introduce far-reaching modifications intherapeutic regimes that will contrast with the traditional options available. Investigational lines that are already active in the clinical research phase with BCG and, checkpoints inhibitors ofthe immune response are also analyzed, high lighting theneed to find predictive response markers as a real option for treatments personalization. The approach to the knowledge of the individual reactivity of the immune system of each patient as a determining factor to achieve it is proposed.

Los abordajes terapéuticos para los carcinomas de células transicionales del urotelio desarrollados en torno a la modulación del sistema inmune encuentran, en la contribución del Bacillus de Calmettey Guérin (BCG) intravesical y más reciente la de los fármacos inhibidores de los puntos de control de la respuesta inmunitaria, indiscutibles pruebas de concepto de la indicación inmunoterapia antitumoral. Su extensión y desarrollo en el momento actual abarca todas las localizaciones del amplio espectro de presentación y evolución de estos tumores. A excepción, por el momento, de los tumores no-músculo infiltrantes debajo grado, acudimos a un desarrollo impredecible de la inmunoterapia antitumoral en el cáncer de vejiga no solo como opción en el tratamiento primario de alguno de ellos sino también en pacientes no-respondedores cuando se trata del BCG, de la quimioterapia sistémicao la situación de no-elegibilidad para su indicación. El objetivo de este artículo de revisión es intentar trasladar los mecanismos básicos actuales implicados en las distintas fases de la respuesta antitumoral de los carcinomas de células transicionales con independencia de que sean o no músculo infiltrantes y establecer los fundamentos para su traslación terapéutica por vía intravesical o sistémica. Se describe el papel de las interacciones que se establecen entre las células tumorales uroteliales y los elementos celulares y moleculares del sistema inmune de los pacientes incorporando los relevantes y recientes avances de la inmunobiológica y la caracterización molecular de estos tumores que sin duda introducirán modificaciones de alcance en su evolución y tratamiento que contrastaran con las opciones hasta hace poco tiempo disponibles. También se analizan las líneas de futuro ya activas en fase de investigación clínica con BCG y con inhibidores de los puntos de control de la respuesta inmunitaria destacando la necesidad de avanzar en la búsqueda de marcadores predictivos de respuesta como opción real para la personalización de los tratamientos planteando la aproximación al conocimiento de la reactividad individual del sistema inmune de cada paciente como factor determinante para poder alcanzarla.

Trends in cancer incidence in Uruguay: 2002 -2015 / Tendencias de la incidencia de cáncer en Uruguay: 2002-2015

Abstract Background: Uruguay is the south American country which has the highest cancer incidence and mortality rates. The National Cancer Registry collects data on cancer cases nationwide since 1989 and has reached high quality standards in the last decades. This is the first report on incidence trends. Methods: Data from the National Cancer Registry of all new cases of invasive cancer from twelve sites diagnosed in 2002-2015 was analyzed. Age-standardized rates were calculated. Trends of incidence rates were analyzed using joinpoint regression models. Results: For both, men and women, incidence rates trends for all cancer sites, colo-rectal and bladder cancer remained stable. Esophageal and gastric cancers descended while thyroid and kidney cancer incidence increased. In men lung cancer decreased; testicular cancer increased, and prostate cancer increased at the beginning of the period and decreased in the final years. In women, lung cancer increased, breast cancer remained stable and cervical cancer presented a significant decline from 2005 to 2010 and reached a plateau since then. Conclusion: Cancer incidence dynamics are complex and affected not only by Public Health policies such as tobacco control, vaccination and screening programs, but also by environmental and life style changes and the attitude of the medical community towards the application of diagnostic and therapeutic tools. The aim of this paper is to analyze cancer incidence time trends in the country and provide possible explanations to them.

Resumen Introducción: Uruguay es el país de Sudamerica que tiene las mayores tasas de incidencia y mortalidad por cáncer. El Registro Nacional de Cáncer recoge los datos de cáncer de todo el país desde 1989 y en las últimas décadas ha alcanzado los más altos estándares de calidad. Este es el primer reporte de tendencias de incidencia de cáncer de Uruguay. Métodos: Se analizaron los datos de todos los casos de cáncer invasivo diagnosticados entre 2002 y 2015 incluidos en el Registro Nacional de Cáncer y los de once topografías en particular. Se calcularon las tasas de incidencia estandarizada y se analizaron las tendencias utilizando los modelos de regresión de Joinpoint. Resultados: Las tasas de incidencia de cáncer colorrectal, vejiga y todos los sitios reunidos se mantuvieron estables tanto en hombres como en mujeres. La tasa de incidencia de cáncer de estómago y esófago disminuyeron mientras que las de tiroides y riñón aumentaron. En los hombres, el cáncer de pulmón disminuyó, el cáncer de testículo aumentó y el de próstata aumentó en un lapso inicial y decreció en los últimos años. En las mujeres el cáncer de pulmón aumentó y el de mama se mantuvo estable mientras que el cáncer de cérvix presentó un descenso significativo entre 2005 y 2010 alcanzando una meseta desde entonces. Conclusión: La dinámica de la incidencia de cáncer es compleja y está afectada no sólo por las políticas de Salud Pública como las campañas de control de tabaco, vacunación y programas de tamizaje sino por los cambios ambientales y de los estilos de vida y la actitud de los médicos respecto a la aplicación de técnicas diagnósticas y terapéuticas. En este trabajo se analizan las tendencias de incidencia en el país y se plantean posibles explicaciones para los cambios.

Evaluation of upper tract urothelial carcinomas by contrast-enhanced ultrasound. / Valoración del carcinoma urotelial de vías superiores mediante ecografía con contraste.

AIM: To describe the findings and behaviour of contrast-enhanced ultrasound in the study of upper tract urothelial tumours and to assess its usefulness for diagnosis. MATERIAL AND METHODS: We reviewed our hospital's database over a period of 45 months to identify patients diagnosed with upper tract urothelial carcinomas. We reviewed the findings on mode B-ultrasound, contrast-enhanced ultrasound (location and qualitative assessment of intensity and washout of enhancement), and made a comparison with other techniques (computed tomography or magnetic resonance), and with the surgical specimen. RESULTS: We found 42 patients with a diagnosis of upper tract urothelial carcinoma confirmed with surgery over the period reviewed. Twenty-eight (67%) patients underwent contrast-enhanced ultrasound. Baseline ultrasound showed hydronephrosis with or without ureteral dilatation with echogenic content occupying the renal calyx (6), pelvis (10) or ureter (12). After injection of contrast, enhancement was noticed in 100% of the lesions, with similar intensity to the cortex in 23, and less in 5. Twenty-four lesions showed early washout, before the cortex, between 40 and 55seconds after the injection. The diagnosis was correct in 27 cases. Localisation coincided with the histological specimen in 28 cases, and 3 patients had additional distal carcinoma foci. CONCLUSION: Contrast-enhanced ultrasound is a useful technique for diagnosing upper tract urothelial tumours that increases confidence in the diagnosis.

Laparoscopic nephroureterectomy with laser endoscopic transuretral disinsertion in lateral decubitus: progressive adaptation to retroperitoneocopic approach. / Nefroureterectomía y desinserción transuretral láser-endoscópica en decúbito lateral sin cambio de posición: adaptación progresiva al abordaje por retroperitoneoscopia.

BACKGROUND: The ureteral disinsertion with bladder cuff technique continues to evolve. We present the endoscopic laser transurethral technique combined with a transperitoneal and retroperitoneal laparoscopic approach in lateral decubitus, without patient repositioning, for treating urothelial carcinomas of the upper urinary tract. MATERIALS AND METHODS: We present 3 laparoscopic nephroureterectomies: 1 transperitoneal and 2 retroperitoneal. Disinsertion was performed in lateral decubitus using a flexible cystoscope and a 365-µm holmium laser fiber. The endoscopic technique was progressively adapted to 3-port and single-port retroperitoneoscopic approaches. Before laparoscopic handling of the kidney, ureter was clamped below the tumour. The endoscopic technique was then started. Both approaches were simultaneously employed. RESULTS: Nephroureterectomies were achieved performing en bloc endoscopic disinsertion of the bladder cuff and ensuring a closed system comparable to open technique. The second case required reconversion due to technical problems and extension of the surgical time. No relapses were diagnosed during follow-up. CONCLUSION: Results are comparable to open surgery, technique ensured compliance to oncology principles, enabled disinsertion in lateral decubitus and avoid patient repositioning saving surgical time. The results reflect the benefits of minimally invasive surgery in all cases.

Lymphoepithelioma-like carcinoma of the urinary bladder: A case report.

We report a case of lymphoepithelioma-like carcinoma of the urinary bladder in an elderly female patient. A 97-year old woman presented with hematuria, and an ultrasonographic urinary study showed a localized tumor in the trigone region of the urinary bladder. A transurethral resection revealed a mixed tumor formed by high-grade transitional carcinoma and lymphoepithelioma-like carcinoma that had infiltrated into the muscular propria. We describe the clinicopathological, morphological and immunohistochemical features of this tumor and briefly discuss its differential diagnosis and biological behavior.

Influence of the true number of Bacillus Calmette-Guérin instillations on the prognosis of non-muscle invasive bladder tumors.

OBJECTIVES: To analyze if the true number of BCG instillations applied in non-muscle invasive bladder tumors has any influence on their prognosis as well as other tumor and clinical characteristics: age, sex, different protocols, BCG dose, whether primary or recurrent, solitary or multiple, tumor size G3 or Cis. PATIENTS AND METHODS: A total of 324 high grade NMIBC (15 TaG3, 184 T1G3, 125 Cis) out of 1491 cases included in the CUETO database were analyzed. Following 6 post transurethral resection (RTU) BCG instillations, the patients were scheduled to receive one instillation every two weeks (3-6 times), for a total of 9-12 instillations. One third of the dose (27 mg) (112 cases) or total dose of 81 mg (212 cases). Mean follow-up was 59.6 months. Statistical Analysis: Kaplan-Meier, Cox-regression (uni-multivariate). RESULTS: A higher level of recurrence (p = 0.032) and progression (P = .013) risk as well as worse Ca-specific survival (P = .005) were obtained if there were fewer than 12 instillations with the Kaplan-Meier and Cox-regression multivariate analysis. A 27 mg (P = .008) dosage and being a female (P < .001) were independent factors for a higher recurrence risk, but not for progression or Ca-specific survival. The remaining characteristics studied were not statistically significant. CONCLUSIONS: In accordance with the results obtained, we can conclude that the number of BCG instillations applied has some influence on the outcome of high grade NMIBC. The optimum number of instillations as well as their time of application must still be determined. A dose of 27 mg and being a female are predictive factors of recurrence.

Tumor de Brenner maligno: caso clínico / Malignant Brenner tumor: clinical case

El tumor de Brenner es una neoplasia rara, que representa el 1-2 por ciento de las neoplasias de ovario. La mayoría son benignas, pero existe un pequeño porcentaje de casos de tumor de Brenner maligno, entre ellos el caso que se presenta. Se trata de una mujer de 41 años que presentó una tumoración ovárica cuyo resultado anatomopatológico fue de carcinoma pobremente diferenciado, con asociación de tumor tipo Brenner maligno. A pesar de ser diagnosticado en estadio precoz, este caso destaca por su mal pronóstico.

Brenner tumor is a rare neoplasia, accounting for 1-2 percent of ovarian cancer. Most of them are benign, but there are a small percentage of malignant Brenner tumors, including the case presented. This is a 41-year-old woman who presented an ovarian tumor. Definitive histological result showed a poorly differentiated carcinoma, with association of malignant Brenner tumor. Despite being diagnosed in early stages, this case stands out for its poor prognosis.

Manejo percutáneo de tumores de células transicionales de la pelvis renal: serie de casos y revisión de la literatura / Percutaneous treatment of renal pelvis transitional cell tumors: case series and review of the literature

Introducción: El carcinoma de células transicionales de la vía urinaria superior es una condición poco frecuente. Poseen un alto porcentaje de recidivas y las alternativas terapéuticas son numerosas. El gold standard terapéutico es la nefroureterectomía radical. Ésta se asocia a una mayor incidencia de insuficiencia renal y muerte por condiciones relacionadas a ésta. Actualmente se encuentran en desarrollo varias terapias con preservación renal, técnicas mínimamente invasivas entre las cuales las principales son la resección por vía percutánea y la resección endoscópica por ureter o nefros copia. Material y método: presentamos una serie de casos de cuatro pacientes portadores de CCT-VUS sometidos a tratamiento percutáneo. Resultados: el tamaño tumoral promedio fue de 14,5 mm (8–20 mm), tres de ellos presentaron lesiones no invasoras y uno de ellos una lesión invasora. No hubo mayores complicaciones, el sangrado promedio fue de 225 cc, ningún paciente requirió de transfusiones de hemoderivados y la estadía hospitalaria de 3,75 días en promedio. Sólo uno de los paciente requirió de tratamiento complementario (tumor invasor), siendo sometido a una nefroureterectomía radical laparoscópica. Actualmente todos los pacientes se encuentran en remisión completa con un tiempo de seguimiento promedio de 50,25 meses (34-61). Conclusiones: el tratamiento percutaneo de los CCT-VUS es una alternativa válida, asociada a una baja taza de complicaciones y segura desde el punto de vista oncológico.

Introduction: Transitional cell carcinoma of the upper urinary tract is an uncommon disease. They have a high percentage of recurrences and the therapeutic approaches are numerous. The treatment gold standard is radical nephrouretherectomy. This is associated with a higher incidence of chronic renal failure y dead from associated conditions. Actually, various nephron sparring therapies are in development. The main techniques are the percutaneous resection and the ureteroscopic resection. Matherials and methods: we present a case series of four patients diagnosed with transitional cell carcinoma of the upper urinary tract treated by a percutaneous approach. Results: mean tumor size was 14.5 mm (8–20 mm), three of them had superficial tumors and one of them invasive ones. There was no mayor complications, average bleeding was 225 cc, no patient needed blood transfusions and mean hospitalization time was 3.75 days. Only one patient required complementary treatment (patient with invasive tumor), being treated with laparoscopic radical nephrouretherectomy. Actually all patients are at complete response to treatment, with an average follow up time of 50.25 months (34-61).Conclusions: percutaneous approach for transitional cell carcinoma of the upper urinary tract is a valid treatment option, associated with a low complications rate and safe form an oncological view. Key words: transitional cell carcinoma of the upper urinary tract, percutaneous surgery, chronic renal failure.

Tumor de Brenner bilateral benigno / Bilateral benign Brenner tumor

El tumor de Brenner es un tumor raro que representa aproximadamente el 1,5 por ciento de los tumores de ovario. Se define como un tumor de células transicionales compuesto por células uroteliales dispuestas en agregados sólidos o quísticos embebidos en un estroma fibroso. Se clasifica en tumor de Brenner benigno (95 por ciento), borderline (3-4 por ciento) y maligno (1 por ciento). Presentamos el caso clínico de una paciente de 91 años intervenida por una tumoración anexial gigante en la que el estudio anatomopatológico reveló la presencia de un tumor de Brenner bilateral benigno asociado a dos cistoadenomas serosos de ovario derecho.

Brenner's tumor is a rare tumor that represents approximately 1.5 percent of the tumors of ovary. It is defined as a tumor of transitional cells composed by cells uroteliales arranged in solid or cystic acccumulations absorbed in a fibrous estroma. It qualifies in tumor of benign Brenner (95 percent), borderline (3-4 percent) and malignantly (1 percent). We present the clinical case of a 91-year-old patient controlled by a giant anexial mass in whom the pathology study (biopsy) revealed the presence of a tumor of bilateral benign Brenner associated with two cistoadenomas serous of right ovary.

Carcinoma de células transicionales del tracto urinario superior: opciones de tratamiento actual y abordajes mínimamente invasivos / Upper urinary tract transitional cell carcinoma: current treatment overview of minimally invasive approaches

Las indicaciones para el manejo mínimamente invasivo de los tumores del tracto urinario superior están en constante expansión. El desarrollo de equipamiento endoscópico cada vez más sofisticado ha llevado a un cambio en la práctica diaria y a una tendencia al manejo conservador. Nuestro objetivo es revisar las diferentes opciones de manejo mínimamente invasivo para el manejo de los tumores del tracto urinario superior, con énfasis en laparoscopia, ureteroscopia y cirugía percutánea.

The indications for minimally invasive treatment for are expanding. The development of more sophisticated endoscopic equipment has led to changes in everyday practice and a trend towards more conservative management. Our objective is to make a review of the different options for management UUT-TCC, with emphasis in laparoscopy, ureteroscopy and percutaneous surgery.

Carcinoma de células transicionales en paciente con enfermedad poliquística renal autosómica dominante / Transitional cell carcinoma in a patient with autosomal dominant polycystic renal disease

Objetivo: Reportar un caso de una paciente con enfermedad poliquística renal autosómica dominante(EPRAD) asociada a la presencia de un carcinoma de células transicionales (CCT).Métodos: Paciente de 46 años de edad, con antecedentes de tabaquismo crónico. Se realiza el diagnóstico de EPRAD complicada con hematuria recurrente con origen en la unidad renal derecha. Resultados: Se realiza nefrectomía laparoscópica mano asistida con un tiempo operatorio de 1 hora25 minutos. El informe anatomopatológico de la pieza operatoria es compatible con carcinoma de CCT Grado 1 de Ash, correspondiendo a un estadio T1 N0 M0 de la Clasificación TNM de la AJCCUICCde 1997.Conclusión: Si bien la existencia de neoplasias renales en pacientes portadores de EPRAD constituye una entidad poco común, y que no presenta mayor incidencia que en la población general, debe considerarse como posibilidad diagnóstica en todos aquellos pacientes que evidencien síntomas o signos de complicación de su enfermedad poliquística, sobre todo en aquellos en los que se plantea la resolución quirúrgica de su patología.

Objetive: We report a patient with autosomal dominant polycystic renal disease (ADPRD) associated with transitional cell carcinoma (TCC).Methods: A 46 year old patient with history of chronic cigarette smoking was diagnosed of ADPRD with recurrent hematuria originated in the right renal unit. Results: A right hand-assisted laparoscopic nephrectomy was performed. Operative time was 85minutes. Pathological analysis showed a Grade 1 TCC, pT1 N0 M0.Conclusions: Renal neoplasias in ADPRD patients are infrequent baring the same incidence as normal patients. However, in symptomatic ADPRD patients, renal neoplasias should be kept in mind, especially if patients are to undergo surgery.