Adilson Prando

Renal cell carcinoma: histological classification and correlation with imaging findings

Renal cell carcinoma (RCC) is the seventh most common histological type of cancer in the Western world and has shown a sustained increase in its prevalence. The histological classification of RCCs is of utmost importance, considering the significant prognostic and therapeutic implications of its histological subtypes. Imaging methods play an outstanding role in the diagnosis, staging and follow-up of RCC. Clear cell, papillary and chromophobe are the most common histological subtypes of RCC, and their preoperative radiological characterization, either followed or not by confirmatory percutaneous biopsy, may be particularly useful in cases of poor surgical condition, metastatic disease, central mass in a solitary kidney, and in patients eligible for molecular targeted therapy. New strategies recently developed for treating renal cancer, such as cryo and radiofrequency ablation, molecularly targeted therapy and active surveillance also require appropriate preoperative characterization of renal masses. Less common histological types, although sharing nonspecific imaging features, may be suspected on the basis of clinical and epidemiological data. The present study is aimed at reviewing the main clinical and imaging findings of histological RCC subtypes.

Focal prostatic atrophy: mimicry of prostatic cancer on TRUS and 3D-MRSI studies

Prostatic atrophy which represents a form of adaptive response to injury most commonly to inflammation and/or chronic ischemia is a histological abnormality frequently found in prostate biopsies and autopsies. Although commonly found, this lesion is rarely reported in the prostatic biopsy reports. It is well known that histologically focal prostatic atrophy (FPA) is one of the most frequent mimics of prostatic adenocarcinoma. On conventional and color Doppler transrectal ultrasound and on magnetic resonance spectroscopic imaging studies (MRSI), FPA may also simulate prostate cancer. Thus, this entity should be considered together with prostatitis as an important cause of false-positive results in MRSI of the prostate. It has been shown that there is a positive and significant association between extent of FPA in biopsies and serum total or free PSA elevation. For this reason, pathologists should include the presence of FPA in the pathology report of a prostatic biopsy, particularly in those patients with absence of cancer. When extensive FPA is the only finding in patients with several negative prostatic biopsies, this lesion may be the source for PSA elevation.

Endorectal magnetic resonance imaging in persistent hemospermia

OBJECTIVE To present the spectrum of abnormalities found at endorectal magnetic resonance imaging (E-MRI), in patients with persistent hemospermia. MATERIALS AND METHODS A review of E-MRI findings observed in 86 patients with persistent hemospermia was performed and results compared with those reported in the literature. Follow-up was possible in 37 of 86 (43%) patients with hemospermia. RESULTS E-MRI showed abnormal findings in 52 of 86 (60%) patients with hemospermia. These findings were: a) hemorrhagic seminal vesicle and ejaculatory duct, isolated (n = 11 or 21%) or associated with complicated midline prostatic cyst (n = 10 or 19.0%); b) hemorrhagic chronic seminal vesiculitis, isolated (n = 14 or 27%) or associated with calculi within dilated ejaculatory ducts (n = 2 or 4 %); c) hemorrhagic seminal vesicle associated with calculi within dilated ejaculatory duct (n = 4 or 7.7%) or within seminal vesicle (n = 4 or 7.7%); d) non-complicated midline prostatic cyst (n = 6 or 11.5%); and e) prostate cancer (n = 1 or 2%). Successful treatment was more frequent in patients with chronic inflammatory and/or obstructive abnormalities. CONCLUSION E-MRI should be considered the modality of choice, for the evaluation of patients with persistent hemospermia.

Abruptio Placentae during Fetal Myelomeningocele Repair

Myelomeningocele (MM) is a congenital neural tube defect with serious consequences, including hydrocephaly. An important hope for intrauterine repair is that hydrocephaly may be prevented by reversing the Arnold-Chiari malformation. Three medical centers in the United States are doing trials with this objective. We describe an intrauterine correction of MM in a Brazilian research center of fetal medicine, which resulted in abruptio placentae and fetal death, to illustrate factors that influence fetal-maternal risks during this surgical procedure.

Prostatic atrophy: Evidence for a possible role of local ischemia in its pathogenesis

Prostatic atrophy may be histologically and at ultrasound similar toadenocarcinoma causing diagnostic confusion, its frequency increaseswith age but the etiopathogenesis is unknown. Based on a systematicstudy in autopsies previously done by one of us, ischemia due to localintense arteriosclerosis seems to be a potential factor for itspathogenesis. Absent blood flow in areas of prostatic atrophy might be afurther evidence for a possible role of ischemia. From a total of 298patients biopsied and studied by gray-scale and color Dopplertransrectal ultrasound in the period 1998 to 2001, 33 patietns hadsuspicious lesions (37 hypoechoic nodules and 3 heterogeneous lesions)showing prostatic atrophy as the only diagnosis on all these biopsiedlesions. Adenocarcinoma, high-grade intraepithelial neoplasia or otheratypical lesions were absent in all patients. On color Doppler thesuspicious areas showed absent flow in 24/40 (60%), presentflow in 12/40 (30%), and increased flow in 4/40(10%) of the lesions. Absent flow in the majority of the lesionsstudied may be a further evidence for a possible role of local ischemiain the etiopathogenesis of prostatic atrophy.

Paraganglioma of seminal vesicle and chromophobe renal cell carcinoma: a case report and literature review

CONTEXT Extra-adrenal paragangliomas are rare tumors that have been reported in many locations, including the kidney, urethra, urinary bladder, prostate, spermatic cord, gallbladder, uterus and vagina. CASE REPORT This report describes, for the first time to the best of our knowledge, a primary paraganglioma of the seminal vesicle occurring in a 61-year-old male. The patient presented persistent arterial hypertension and a previous diagnosis of chromophobe renal cell carcinoma. It was hypothesized that the seminal vesicle tumor could be a metastasis from the chromophobe renal cell carcinoma. Immunohistochemical characterization revealed expression of synaptophysin and chromogranin in tumor cell nests and peripheral S100 protein expression in sustentacular cells. Succinate dehydrogenase A and B-related (SDHA and SDHB) expression was present in both tumors. CONCLUSIONS No genetic alterations to the VHL and SDHB genes were detected in either the tumor tissue or tissues adjacent to the tumor, which led us to rule out a hereditary syndrome that could explain the association between paraganglioma and chromophobe renal cell carcinoma in a patient with arterial hypertension.

Abdominal manifestations of extranodal lymphoma: pictorial essay

In the appropriate clinical setting, certain aspects of extranodal abdominal lymphoma, as revealed by current cross-sectional imaging techniques, should be considered potentially diagnostic and can hasten the diagnosis. In addition, diagnostic imaging in the context of biopsy-proven lymphoma can accurately stage the disease for its appropriate treatment. The purpose of this article was to illustrate the various imaging aspects of extranodal lymphoma in the abdomen.

Achados da tomografia computadorizada em metástases pancreáticas do carcinoma de células renais

OBJETIVO: Apresentar os achados da tomografia computadorizada observados em quatro pacientes submetidos a nefrectomia radical por carcinoma de celulas renais e que apresentaram metastases pancreaticas. MATERIAIS E METODOS: Os quatro pacientes foram submetidos a nefrectomia radical por carcinoma de celulas renais, estadios T1 (n=2) e T3a (n=2). O intervalo medio entre a nefrectomia e a deteccao das metastases foi de oito anos. Dois pacientes apresentaram metastase pancreatica solitaria (confinada ao pâncreas) e dois apresentaram metastases pancreaticas unica e multiplas, respectivamente, ambos com recorrencia tumoral no rim contralateral. RESULTADOS: As metastases pancreaticas foram visualizadas, na tomografia computadorizada, como lesoes hipervascularizadas, solitaria (n=2), unica (n=1) ou multiplas (n=1). Foi realizada pancreatectomia parcial em dois pacientes com metastase solitaria. Estes pacientes estao livres da doenca quatro e dois anos apos a cirurgia, respectivamente. CONCLUSAO: Metastases pancreaticas de carcinoma de celulas renais sao raras, podendo ocorrer muitos anos apos a apresentacao inicial. Metastases pancreaticas multiplas e metastases pancreaticas associadas a recorrencia tumoral no rim contralateral sao incomuns. A tomografia computadorizada, as metastases pancreaticas aparecem como lesoes hipervascularizadas e solitarias, simulando tumores das ilhotas celulares. O tratamento cirurgico das lesoes solitarias deve ser considerado.

Radiological classification of renal angiomyolipomas based on 127 tumors

PURPOSE Demonstrate radiological findings of 127 angiomyolipomas (AMLs) and propose a classification based on the radiological evidence of fat. MATERIALS AND METHODS The imaging findings of 85 consecutive patients with AMLs: isolated (n = 73), multiple without tuberous sclerosis (TS) (n = 4) and multiple with TS (n = 8), were retrospectively reviewed. Eighteen AMLs (14%) presented with hemorrhage. All patients were submitted to a dedicated helical CT or magnetic resonance studies. All hemorrhagic and non-hemorrhagic lesions were grouped together since our objective was to analyze the presence of detectable fat. Out of 85 patients, 53 were monitored and 32 were treated surgically due to large perirenal component (n = 13), hemorrhage (n = 11) and impossibility of an adequate preoperative characterization (n = 8). There was not a case of renal cell carcinoma (RCC) with fat component in this group of patients. RESULTS Based on the presence and amount of detectable fat within the lesion, AMLs were classified in 4 distinct radiological patterns: Pattern-I, predominantly fatty (usually less than 2 cm in diameter and intrarenal): 54%; Pattern-II, partially fatty (intrarenal or exophytic): 29%; Pattern-III, minimally fatty (most exophytic and perirenal): 11%; and Pattern-IV, without fat (most exophytic and perirenal): 6%. CONCLUSIONS This proposed classification might be useful to understand the imaging manifestations of AMLs, their differential diagnosis and determine when further radiological evaluation would be necessary. Small (< 1.5 cm), pattern-I AMLs tend to be intra-renal, homogeneous and predominantly fatty. As they grow they tend to be partially or completely exophytic and heterogeneous (patterns II and III). The rare pattern-IV AMLs, however, can be small or large, intra-renal or exophytic but are always homogeneous and hyperdense mass. Since no renal cell carcinoma was found in our series, from an evidence-based practice, all renal mass with detectable fat should be considered an AML.

Massive Intratubular Hemorrhage with Herniations into Renal Veins: Report of a Case

A 24-year-old man had unilateral gross hematuria that required nephrectomy. Pathological examination revealed massive intratubular hemorrhage and frequent deposition of an amorphous and homogeneous material positive for periodic acid, Schiff stain in the corticomedullary junction. This substance had the characteristics of Tamm-Horsfall protein and frequently herniated into the lumen of thin-walled veins of arcuate size. There was no apparent cause for the bleeding. To the best of our knowledge this is the third reported case with these peculiar findings and no apparent cause. We discuss some hypotheses as to the etiopathogenesis of this rare and intriguing condition.