Micropapillary urothelial carcinoma of the urinary bladder: Early surgery or neoadjuvant chemotherapy?

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Background: Micropapillary bladder carcinoma is a rare variant of urothelial carcinoma (UC) of the urinary bladder. As a particularly aggressive variant, patients are often urged to undergo up-front radical cystectomy. Though data is scarce on the treatment outcomes of patients with this entity, we present the case for neoadjuvant chemotherapy as opposed to early cystectomy in the setting of clinically localized micropapillary UC. Methods: A review of records of all patients evaluated at our institution for UC was conducted to identify micropapillary UC of the bladder over the period from 2000–2007. A total of 24 cases were found, and were evaluated for preoperative pathology and clinical stage, treatment course, pathological stage and cancer specific survival. Results: Mean patient age was 67.9 years with 19 males and 5 females. Twenty-one (87.5%) patients had clinically organ confined micropapillary UC at the time of diagnosis, three had minimally enlarged lymph nodes on pelvic CAT scans. Half of our patients had BCG refractory high grade non-muscle invasive UC. Twenty-two patients (91.67%) were offered radical cystectomy as first line management. Extended lymph node dissection was performed in eleven patients (45.83%). Final pathologic examination diagnosed metastatic lymph node involvement in 20 patients (83.33%), with 4 patients (20%) having positive LN outside the standard (pelvic) template of dissection. A stage upgrade was noticed in 95.23% of cases. Median cancer specific survival was 13 months. Survival at one year was 44% and 50% at 2years, with only one patient alive at 5 years. Conclusions: Our results suggest that clinically localized micropapillary UC is often metastatic to LN at the time of presentation. This setting of frequent systemic disease should encourage standard neoadjuvant chemotherapy rather than early surgical management for these patients. Extended LN dissection is warranted in these cases due to the high incidence of nodal involvement outside the standard template.

No significant financial relationships to disclose.

237 INCREASE OF BLASTOCYST DEVELOPMENTAL RATE IN VITRO BY SELECTION OF DEVELOPMENTALLY COMPETENT COW OOCYTES BEFORE IVM USING A STAINING TEST

A large proportion of bovine oocytes fail to develop to blastocyst stage following maturation, fertilization, and culture in vitro. While suboptimal culture conditions undoubtedly contribute to this poor development, it is recognized that immature oocytes, especially from cows with reduced reproductive performance or which are slaughtered on the end of their use, are heterogeneous in quality and developmental competence (Gordon 2003). The aim of the present study was to increase the efficiency of blastocyst production from cows after IVM/IVF by oocyte selection before maturation. Immature oocytes are known to synthesize a variety of proteins (Wassarman PM 1988, Annu. Rev. Biochem. 57, 415–442), among them, glucose-6-phosphate dehydrogenase (G6PDH). This enzyme is active in the growing oocyte, but has decreased activity in oocytes that have finished their growth phase. Brilliant cresyl blue (BCB) has been used to measure G6PDH activity. The BCB test is based on the capability of the G6PDH to convert the BCB stain from blue to colorless (Erisson et al. 1993 Theriogenology 39, 214). The ovaries were obtained from a slaughterhouse and transported to the laboratory; cumulus-oocyte complexes (COCs) were recovered by slicing the surface of the ovary. Only oocytes with a compact cumulus investment were used. Oocytes were placed into three groups: (1) control – placed immediately into culture; (2) holding control – COCs kept in PBS containing 0.4% BSA for 90 min at 38.5°C before placement into culture; and (3) treatment – incubation with brilliant cresyl blue for 90 min at 38.5°C before culture. Treated oocytes were then divided into BCB− (colorless cytoplasm, increased G6PDH) and BCB+ (colored cytoplasm, low G6PDH) on their ability to metabolize the stain. Activity of G6PDH was determined via measurement of NADP reduction in control, BCB−, and BCB+ groups; activity was significantly increased in BCB− COCs in comparison to the control and BCB+ COCs. After IVM, oocytes were fertilized in vitro. Embryos were cultured to Day 8. The rate of maturation to metaphase II was significantly higher for control and BCB+ oocytes (77.1 and 72.5%, respectively) than for BCB− oocytes (58.1%). The BCB+ oocytes yielded a significantly higher proportion of blastocysts (34.1%) than either control group (18.3 and 19.2%); and both controls and BCB+ oocytes had significantly higher blastocyst development than did BCB− oocytes (3.9%). The number of nuclei in the blastocysts was comparable in BCB+ and both control groups (105.5 ± 5.8 and 117.5 ± 8.5, 101.8 ± 6.2, respectively). Blastocysts in the BCB− group had a significantly lower cell number (61.0 ± 2.6) than did controls. The results show that the staining of COCs from cows before IVM may be useful in increasing the efficiency of blastocyst production during standard IVF procedures. In addition, classification of G6PDH activity on the basis of BCB staining may be used to effectively select cow oocytes with further developmental competence. To our knowledge, this is the first study to evaluate the association between G6PDH activity in oocytes and further blastocyst development in cows.

Idiopathic purpura fulminans and varicella gangrenosa of both hands, toes and integument in a child

Chicken pox is a common childhood illness and, though a vaccine is readily available, it is not routinely included in the vaccination schedule of most countries owing to its mild clinical nature. However, varicella gangrenosa is a rare complication of this disease, infrequently reported in the literature. We report the case of a child who developed purpura fulminans in the convalescent phase of chicken pox and subsequently presented with peripheral gangrene of both hands and the toes of the right foot, and skin gangrene. To our knowledge, bilateral gangrene of the hands has rarely been reported, and we present this case to highlight the serious nature of complications following varicella infection.

Radiographic spectrum of rectocolonic calcification from schistosomiasis

Rectocolonic calcification was detected radiographically in 17 sites in 14 patients undergoing excretory urography for the assessment of urinary schistosomiasis. The right colon was involved in 11 sites, the rectum in four, and the left colon in two. The pattern of calcification varied according to the degree of bowel distension. A laminar pattern was common to all sites and occurred when the rectum or colon was distended with air, feces, or barium. A laminar or irregular amorphous density was found in the empty colon, whereas the calcified, empty rectum had a corrugated pattern. Rectocolonic calcification is probably the most common radiographic manifestation of schistosomal infestation of the gastrointestinal tract.