Intratumoral Heterogeneity, Chemoresistance and Lymph Node Landing Zone Prognosis in Testicular Tumors Based on Histopathological Characteristics

BACKGROUND

Existing data on the histopathological correlation of testicular tumors with lymph node prognosis have been poorly explored. We aimed to investigate the relationship of the histopathological properties of testicular tumors with lymph nodes and their involvement with chemoresistance and heterogeneity of testicular tumors.

METHODS

Patients with non-seminomatous germ cell tumor (NSGCT) were selected for histopathological correlation of testicular tumor with lymph nodes and its relationship with chemoresistance and heterogeneity. Histopathological and radiological parameters associated with the risk of chemoresistance and tumor progression were measured pre- and post-chemotherapy. Binomial logistic regression and Kaplan-Meier analysis were implemented to determine the predictors of progression and adverse overall patient survival. All categorical variables were analyzed using the Chi-square test, while Pearson's R coefficient determined the correlation.

RESULTS

Male patients who were diagnosed with NSGCT from March 2017 to December 2018 at Guwahati Medical College, Guwahati, India, were included in this study. Lymph node groups were predominantly incriminated with the EYST or EYS groups and minimally linked with the pure E and YCS groups. Furthermore, the highest number of lymph node stations was associated with pre-chemotherapy. In salvage chemotherapy in the form of VIP, we found exciting outcomes, as approximately 41% of cases responded positively, especially in the EYS group.

CONCLUSION

Our study classifies NSGCT according to the most favorable histopathological grouping and explores the tumoral response in different intrinsic and extrinsic variables. Our analysis can serve as a triumphant histopathological nomogram for a sublime management protocol to deal with the onerous histological pairing in NSGCT.

Skeletal-Related Events in Renal Cell Carcinoma: Prediction With Alkaline Phosphatase (ALP), C-reactive Protein (CRP), Haemoglobin (Hb) and Erythrocyte Sedimentation Rate (ESR) (A.C.H.E.) Score for Risk Stratification

Introduction  Skeletal metastasis is catastrophic in patients with renal cell carcinoma (RCC), leading to skeletal-related events (SRE) such as nerve entrapment, hypercalcemia and even pathological fractures, which may require surgical intervention. The nature of the bone metastasis in advanced RCC is large, destructive, hyper-vascular and mostly lytic. The present retrospective analysis aims to identify potential risk factors for predicting SREs in advanced RCC with bone metastasis. Methods The clinical data of 42 patients with RCC and bone metastasis and at least one episode of SRE were reviewed, and the correlations between erythrocyte sedimentation rate (ESR), alkaline phosphatase (ALP), C-reactive protein (CRP), haemoglobin (Hb), carcinoembryonic antigen (CEA) and bone metastases were analysed. Risk factors were identified by multivariate logistic regression analysis. Bone metastasis was diagnosed on a bone scan. The receiver operating characteristic (ROC) curve calculated the cut-off value of the independent correlation factors. Results The areas under the ROC curve for ALP, Hb, CRP, and ESR were 0.84, 0.76, 0.86 and 0.88, respectively, suggesting excellent discriminatory capability of ALP, CRP, ESR and sufficient discriminative ability of Hb in predicting bone metastasis. Multivariate logistic regression analysis showed ALP, CRP, Hb and ESR associated with SRE and skeletal metastasis. Conclusion We propose that an A.C.H.E. score encompassing ALP, CRP, Hb, and ESR are potential risk factors for developing SRE and concomitant bone metastasis in advanced RCC patients. For new RCC patients, if values of ALP >128 U/L, CRP ≥74 mg/L, Hb <11.5 g/L, and ESR ≥55 mm/hr are detected, intensive monitoring and bone scanning are warranted as these cases are at a higher risk of skeletal events.

Association of Radiological Features with Histological Features in Patients with Renal Cell Carcinoma: A Cross-sectional Study

Introduction: Renal Cell Carcinoma (RCC) is a group of neoplastic lesions with unique cytogenetic characteristics and histopathological features. The majority of studies till date on RCC have been focusing on tissue histology to plan neoadjuvant treatment in clinical settings. An accurate forecast of the histopathological subtype has clinical implications in management and response to newer treatment strategies. It is pertinent to preoperatively distinguish a solid renal masses histologically but, there are currently no well-established imaging criteria to classify these tumors on the basis of radiographic evaluation. Aim: To evaluate the differences in imaging characteristics of different histological subtypes of RCC by Power Doppler Ultrasound and Multi-Detector Computed Tomography (MDCT) scan. Materials and Methods: This cross-sectional study was conducted in the Department of Urology, Gauhati Medical College and Hospital, Guwahati, Assam, from March 2016 to December 2017. The study population consisted of 61 patients of RCC who were evaluated with MDCT and Doppler ultrasound prior to surgery and findings were correlated with histopathological forms of tumour. The Pearson Chi-square test and ANOVA test was used to statistically analyse the data. Results: Histopathology revealed clear cell Renal Cell Carcinoma (ccRCC), chromophobe Renal Cell Carcinoma (chRCC) and papillary Renal Cell Carcinoma (pRCC) in 52, 4 and 5 patients, respectively. Heterogenous enhancement was found in 51 cases and among these 90.4% were ccRCC. Absolute attenuation values in Corticomedullary Phase (CMP) and Nephrographic Phase (NP) for clear cell and chromophobe subtype were higher than papillary subtype, i.e., 88.04±30.40 Hounsfield Unit (HU) and 72.41±20.17 HU for clear cell, 60.75±22.54 HU and 88±16.06 HU for chromophobe; 22.40±12.52 HU and 58.00±4.41 HU for papillary subtype, respectively. Papillary RCC (pRCC) showed a unique enhancement pattern, with a low peak enhancement (average peak of 55.40 HU) and greatest enhancement during the NP. In this study population ccRCC, ChRCC RCC and pRCC had mean Resistive Index (RI) of 0.63±0.06, 0.58±0.0 and 0.67±0.11, respectively. Conclusion: Power doppler flow imaging is not useful in discriminating subtypes of RCC while multiphasic Computed Tomography (CT) imaging may be useful, particularly the phasic enhancement pattern to distinguish common RCC subtypes which may facilitate treatment planning and choosing appropriate tyrosine kinase inhibitors.

Role of diffusion-weighted MRI for prediction of regional lymph node positivity in radiologically organ-confined renal tumour: a prospective study

Background

Lymph node metastasis is one of the major factors that decide the prognosis of renal cell carcinoma. Presently, lymphadenectomy is only accepted as the most precise and dependable staging method to detect lymph node invasion; still, its therapeutic value for renal cell carcinoma is controversial. Diffusion-weighted magnetic resonance imaging along with its apparent diffusion coefficient value has already shown great value as a non-invasive modality to detect early microstructural changes in various human tumours. The present study is done to know the role of DWMRI in determining regional lymph node positivity in radiologically organ-confined renal cell carcinoma.

Methods

In this prospective study, we measured the ADC value of renal mass and regional lymph node in patient of RCC. ADC value < 1.25 is taken as cut-off to determine lymph node involvement. A malignant lymph node was confirmed by histopathology postoperatively. After that, we analysed the data retrospectively and studied the association between cut-off ADC value and lymph node positivity.

Results

Total 44 patients of RCC were evaluated in the study. Out of 44 patients, lymph node was found to be malignant on histopathology in 25 (56.8%) patients, and of these, 23 patients had ADC value < 1.25. This association was statistically significant (p < 0.05). The findings of DW MRI were accurate in 72.7% of patients with sensitivity of 63.1%, specificity of 80% and positive predictive value of 70.5%.

Conclusions

Lymph node with ADC value < 1.25 × 10–3 mm2/s has higher probabilities of harbouring malignant cell, so ADC value of DWMRI can be used as a sensitive and specific parameter to differentiate malignant lymph node from benign lymph node. However, our futuristic observation needs to be validated by multi-institutional large sample cohort.

Predictors of Progression-Free Survival and Overall Survival in Metastatic Non-Clear Cell Renal Cell Carcinoma: A Single-Center Experience

Background

Due to the infrequency of non-clear cell renal cell carcinoma (RCC), there is currently a paucity of high-quality literature to help guide the effective treatment of these tumors. Recently, biomarkers such as platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), systemic immune inflammation (SII) index and C-reactive protein to albumin ratio (CAR) have been demonstrated to be closely related to poor prognosis of patients with RCC. The objective of this study was to evaluate these biomarkers for determining the progression-free survival (PFS) and overall survival (OS) in patients with metastatic non-clear cell cancer.

Methods

We retrospectively reviewed 31 cases diagnosed with metastatic non-clear cell RCC from January 2012 to December 2017. We assessed the prognostic value (OS and PFS) of pretreatment PLR, LMR, SII index and CAR based on multivariate analysis and Kaplan-Meier survival curve.

Results

Median time of OS and PFS were 15.5 months (95% confidence interval (CI): 13.7 - 15.2) and 10.9 months (95% CI: 8.9 - 12.8), respectively. The median PFS (0.001) and OS (P = 0.01) was shorter in patients with PLR > 171, LMR < 2.61. Moreover, median PFS but not OS was significantly lower in SII index > 883 (P = 0.064) and CAR > 0.11 (P = 0.229). Scan to surgery time (3.91 weeks, P = 0.001) was also significantly related to progression.

Conclusions

Elevated pretreatment inflammatory biomarkers such as PLR, LMR, SII index and CAR are significant determinants of shorter PFS and OS (PLR and LMR only) in patients with metastatic non-clear cell RCC treated with cytoreductive nephrectomy.

Thulium Laser Vaporization versus Vapoenucleation (without morcellation) Technique for BPH: Do We Have a Winner?

Background and ObjectiveThe thulium laser surgery is a relatively new approach in which a wavelength of approximately 2 μm is emitted in continuous-wave mode, thus enabling the precise incision of tissue by using a wavelength that matches the water absorption peak of 1.92 μm in tissue. However, no published multinational study or other evidence definitively declares the superiority of thulium vaporization (ThuVAP) over thulium vapoenucle-ation (ThuVEP) without morcellator for better management of bothersome benign prostatic hyperplasia. The present study aims to evaluate the efficacy of vaporization and vapoenucleation (without a morcellator) in thulium laser prostatectomy for the treatment of benign prostatic hyperplasia.MethodsA retrospective analysis of 82 patients who underwent thulium laser prostatectomy between February 2017 and January 2018 with ThuVAP and ThuVEP techniques was done and outcome measures analyzed were International Prostate Symptom Score (IPSS), quality-of-life score (QoL), maximum flow rate (Q max), post-void residual (PVRU), total operating time, laser time and resected tissue weight.ResultsNo significant differences were noted between ThuVAP and ThuVEP in terms of post-operative prostate volume (22.4 vs. 21.7 mL) and post-operative prostate specific antigen (PSA) (2.54 vs. 1.85 ng/mL). Nonetheless, there were differences between the groups in total lasing time (56.5 vs. 44.8 min, p = 0.001) and total operative time (88.5 vs. 71.5 min, p= 0.001). There was also a significant difference in IPSS, QoL score, Q max, and PVRU at 6 weeks, 3 months, 6 months and 9 months after surgery.

Role of Diffusion-Weighted Magnetic Resonance Imaging (DWMRI) in Assessment of Primary Penile Tumor Characteristics and Its Correlations With Inguinal Lymph Node Metastasis: A Prospective Study

Background

Penile cancer is a rare malignancy. The extent of lymph node (LN) metastasis is the most important prognostic factor in penile cancer. However, preoperative prediction of LN involvement in clinically non-palpable LN is still a challenge. In absence of a reliable biomarker, attempts are being made to validate imaging characteristics as a predictive tool. The aim of the present study is to assess the primary penile tumor characteristics with diffusion-weighted magnetic resonance imaging (DWMRI) and its correlations with inguinal LN status and tumor positivity in LN dissection specimen within normal sized LNs.

Methods

Twenty-six patients with carcinoma penis underwent DWMRI of penis and pelvis. The apparent diffusion coefficient (ADC) values of primary tumor were compared with histological characteristics. Inclusion criteria encompassed all cases of clinically non-palpable inguinal LN and normal sized LN on imaging. All palpable inguinal nodes with pelvic lymphadenopathies were excluded from this study.

Results

The primary tumor ADC ranged from 0.65 × 10^-3 - 1.2 × 10^-3 mm²/s (mean: 0.87 × 10^-3 ± 0.11 × 10^-3 mm²/s). In pT1 and pT3 tumors, mean ADC values were 0.86 × 10^-3 ± 0.10 × 10^-3 and 0.81 × 10³ ± 0.09 × 10³ mm²/s, respectively. The mean ADC values for grade 1, grade 2 and grade 3 were 0.89 × 10^-3, 0.82 × 10^-3 and 0.80 × 10^-3 mm²/s, respectively. The ADC value of < 0.95 × 10^-3 mm²/s was positively correlated with pathological LN presence within normal sized LN. With mean ADC value of 0.87 × 10^-3 ± 0.11 × 10^-3 mm²/s, sensitivity and positive predictive values for primary penile cancer were 100% and 84.61%, respectively. The mean ADC value for higher-grade and -stage tumor was low. The sensitivity and specificity of predicting LN metastasis by DWMRI were 87.22% and 80.90%, respectively.

Conclusion

ADC value of primary tumor can help in prediction of LN metastasis in carcinoma penis with clinically and radiologically normal groin.

Emphysematous infections of the urinary tract - an audit of 20 patients with review of literature

Emphysematous infection of the urinary tract is a rapidly progressive, necrotizing infection which results into collection of gas and subsequent destruction of the tissues. Although very rare among general population, such necrotizing infection is common, particularly among those with compromised immune status. With the rising trend of people afflicted with diabetes mellitus globally, this fulminating infection may pose a serious threat to the medical fraternity. A high index of suspicion and abdominal CT scan usually helps to establish the diagnosis at an early stage and thereby facilitating aggressive antimicrobial therapy and percutaneous drainage where indicated. Although, extirpation of infected renal unit was the treatment of choice earlier, with the advent of modern imaging, endourological procedures and broad spectrum antibiotics, majority of such patients can be treated with minimal morbidity and mortality even with salvaging of the renal units. We present here the outcome of management of 20 cases with varied spectrum of emphysematous infection.

Giant adrenal tumor presenting as Cushing's syndrome and pheochromocytoma: A case report

We report a case of a 35-year-old lady who presented with Cushingoid features and associated raised urinary metanephrine. The patient underwent open adrenelectomy. Histopathological examination revealed adreno-cortical carcinoma with microscopic lymphovascular invasion. Postoperative period was uneventful and is on follow-up for the last one year and is doing well.

Role of primary chemotherapy in management of large tumors of undescended testis: Our experience

OBJECTIVE

This study aimed to share our experience with tumors of undescended testis (UDT) and to assess the impact of primary cisplatin-based chemotherapy on such tumors.

MATERIALS AND METHODS

This study included the cases of tumor in UDT from February 2005 to December 2011. Evaluation of the cases was done with proper clinical examination and laboratory investigations along with tumor markers (alfa-feto protein, beta-human chorionic gonadotropin, lactate dehydrogenase) and contrast-enhanced computed tomography abdomen. Fine needle aspiration cytologywas done in all cases. Primary chemotherapy with three cycles of bleomycin, etoposide, and cisplatin regimen at three weekly intervals started in all cases. Response to treatment was seen after four weeks of the third cycle.

RESULTS

Fourteen cases (12.5%) of germ cell tumor in UDT out of 112 cases of germ cell tumor of the testis were included. The age ranged from 16-60 years. Histological diagnosis was pure seminoma in all cases. After three cycles of BEP regime, complete response was seen in 11 cases and partial response in three cases where the residual tumor was excised along with retroperitoneal lymph node dissection RPLND. Of the 14 cases, 13 were in regular follow-up and one was lost to follow-up. All on follow-up were doing well without recurrence till now.

CONCLUSION

Surgical removal of the primary tumor in UDT with or without bulky metastasis is complicated. Primary chemotherapy with cisplatin-based regimen is a good option in such cases.

An innovative surgical technique for treating penile incarceration injury caused by heavy metallic ring

Penile incarceration injury by heavy metallic ring is a rare genital injury. A man may place metal object for erotic or autoerotic purposes, for masturbation or increasing erection, and due to psychiatric disturbances are some of the reasons for a penile incarceration injury. The incarcerating injury results in reduced blood flow distal to the injury, leading to edema, ischemia, and sometimes gangrene. These injuries are divided into five grades and their treatment options are divided into four groups. Surgical techniques are reserved for the advanced grades (Grades IV and V). We describe an innovative surgical technique, which can be adopted in Grades II and III injuries.