Alaa A. Mokhtar

Bilharzial related, organ confined, muscle invasive bladder cancer: prognostic value of apoptosis markers, proliferation markers, p53, E-cadherin, epidermal growth factor receptor and c-erbB-2.

PURPOSE We investigated the association of the apoptosis related proteins Bcl-2, Bcl-x, Bax and Bak, p53, the adhesion molecule E-cadherin, the receptor proteins epidermal growth factor receptor and c-erbB-2, and the proliferation markers proliferating cell nuclear antigen and Ki-67 with the clinical outcome of bilharzial related transitional cell carcinoma and squamous cell carcinoma. MATERIALS AND METHODS Cystectomy specimens from 109 patients with organ confined, muscle invasive stage, pT2pN0M0, bilharziall positive bladder cancer were examined, including 60 with squamous cell carcinoma and 49 with transitional cell carcinoma. Immunohistochemical results were correlated with tumor progression. RESULTS In squamous cell carcinoma but not in transitional cell carcinoma the loss of epidermal growth factor receptor, Bax and Bak was significantly associated with higher histological grade (p = 0.02, 0.006 and 0.01, respectively). On univariate analysis patients with transitional cell carcinoma had a poorer prognosis than those with squamous cell carcinoma. p53 Over expression and the loss of Bak positivity were associated with shortened progression-free survival in transitional cell carcinoma (p = 0.006 and 0.04, respectively), and squamous cell carcinoma (p = 0.00001 and 0.04, respectively). In squamous cell carcinoma high tumor grade (p = 0.02) and in transitional cell carcinoma high labeling indexes for MIB-1, Bcl-x expression and c-erbB-2 positivity (p = 0.03, 0.02 and 0.04, respectively) were associated with a poorer prognosis. On multivariate analysis p53 emerged as a significant prognostic factor for each condition. Additional independent prognostic factors were proliferating cell nuclear antigen for squamous cell carcinoma, and MIB-1, Bcl-x and Bax for transitional cell carcinoma. CONCLUSIONS Bilharzial related transitional cell carcinoma and squamous cell carcinoma of the bladder differ in interims of protein expression and prognosis. Independent prognostic factors were p53, MIB-1, Bcl-x, and Bax in the former disease, and p53 and proliferating cell nuclear antigen in the latter disease.

Outcome of Penile Cancer in Circumcised Men

PURPOSE We previously reported on a group of patients with post-circumcision carcinoma of the penis. We now study the long-term outcome of these patients. MATERIALS AND METHODS We retrospectively reviewed the available charts of 22 patients presenting between October 1979 and May 2000. RESULTS Of 22 patients 18 underwent ritual circumcision with extensive scar development. Median age at diagnosis was 62.4 years. The penile lesion was dorsal and proximally located in 15 patients. Median delay before diagnosis was 12 months. Clinically 14 patients had stage T1-T2 disease, with 13 having no lymph node involvement and none with distant metastasis, 8 patients had stage T3-T4 disease. A total of 15 patients were treated surgically with total penectomy (10) or conservative local excision (5), inguinal lymph node dissection (9) and subsequent penile reconstruction (3). Pathological staging in 15 patients revealed 10 patients with stage T1 and in 8 patients with lymph node dissection none had nodal metastasis. Histopathological classification was 20 squamous cell carcinoma, 1 sarcoma and 1 verrucous carcinoma. Six patients refused surgery and 1 was referred for palliation. Median followup was 14.5 months and median survival was 14.5 months. The 3-year survival was 42% for stage T1-T2 and 13% for T3-T4 (p = 0.0052). Median survival for the surgical group was 34 months whereas for nonsurgical group was 3 months (p = 0.0016). Recurrence-free survival in the surgical group was 50%. CONCLUSIONS Penile carcinoma in circumcised men is a distinct disease commonly following nonclassic vigorous circumcision. Delayed diagnosis and deferring surgical treatment are associated with increased mortality.

Retrograde vaginal methylene blue injection for localization of complex urinary fistulas

BACKGROUND Ureterovesical and vesicovaginal fistulae usually are easily diagnosed with standard techniques, including radiology, double-dye test, cystoscopy, and vaginal examination. In a few complex cases, however, the localization of the fistulous orifice may be extremely difficult. METHOD We describe a novel technique of retrograde vaginal methylene blue testing that may assist in the proper localization of the fistulous opening. RESULTS Our experience with one case each of ureterovesical and vesicovaginal fistula easily diagnosed with this method proves its efficacy, simplicity, and safety. CONCLUSION This technique should be reserved for cases of urinary fistulae when all standard diagnostic methods have failed.

Laparoscopic Ablation of Giant Renal Cyst

We report a case of a symptomatic giant (18 x 10 x 8-cm) renal cyst in a 40-year-old woman that was marsupialized laparoscopically and excised. The surgical technique, based on progressive decompression of the cyst, is fully described. Excellent results were achieved. The recent application of laparoscopic ablation of different types of renal cysts is reviewed. This minimally invasive technique, when properly mastered, is highly effective and offers results similar to those of open surgery. It is associated with definitive postoperative advantages and is the treatment of choice for very large renal cysts, especially those located anteriorly, when sclerotherapy is ineffective or is contraindicated.

Isolated ureteric endometriosis presenting as a ureteric tumor.

A 32 year old lady presented with recurrent left flank pain for 4 weeks and chronic lower back pain. CT without contrast showed no stones and mild left hydronephrosis. CT of the spine suggested an inflammatory process at L5-S1 vertebra. The diagnosis was supported by a bone scan. Incidentally, the scan showed nonfunctioning left kidney. Diuretic renography confirmed poor perfusion and no excretion. A retrograde study showed narrowing of the ureter at the pelvic brim. Ureteroscopy showed a papillary mass in the lumen of the ureter from which multiple cold cup biopsies were taken. The pathology however was not conclusive. A robotic nephroureterectomy was carried out. Definitive pathology showed intrinsic endometriosis of the ureter. We conclude that endometriosis should be considered in the differential diagnosis of unexplained ureteric obstruction and ureteric lumen filling defects in young women.

Predictors of viable germ cell tumor in postchemotherapeutic residual retroperitoneal masses

Objective: The aim of this study was to identify predictors of viable germ cell tumor (GCT) in postchemotherapeutic residual retroperitoneal masses. Materials and Methods: The pertinent clinical and pathologic data of 16 male patients who underwent postchemotherapeutic retroperitoneal lymph node dissection (PC-RPLND) at King Faisal Specialist Hospital and Research Centre between 1994 and 2005 were reviewed retrospectively. It was found that all patients received cisplatin-based chemotherapy for advanced testicular GCT. Results: Out of the 16 male patients, 2 (13%), 8 (50%), and 6 (37%) had viable GCT, fibrosis, and teratoma, respectively. Ten (10) of the patients with prechemotherapeutic S1 tumor markers did not have viable GCT, and two of the six patients who had prechemotherapeutic S2 tumor markers have viable GCT. All tumor marker levels normalized after chemotherapy even in patients with viable GCT. Four patients had vascular invasion without viable GCT. Furthermore, four patients had more than 60% embryonal elements in the original pathology, but only 1 had viable GCT at PC-RPLND. Four of the five patients with immature teratoma had teratoma at PC-RPLND but no viable GCT; however, out of the four patients with mature teratoma, one had viable GCT and two had teratoma at PC-RPLND. Of the two patients with viable GCT, one had 100% embryonal cancer in the original pathology, prechemotherapeutic S2 tumor markers, history of orchiopexy, and no vascular invasion; the other patient had yolk sac tumor with 25% embryonal elements and 40% teratoma in the original pathology, and prechemotherapeutic S2 tumor markers. Conclusion: None of the clinical or pathological parameters showed a strong correlation with the presence of viable GCT in PC-RPLND. However, patients with ≥S2 may be at higher risk to have viable GCT. Further studies are needed to clarify this.

Is Survival after Radical Cystectomy for Bladder Cancer in Saudi Patients Different from that of Western Patients

BACKGROUND Although radical cystectomy (RC) is considered the gold standard treatment of muscle invasive bladder cancer, nearly half of patients develop metastases and ultimately die within 2 years. OBJECTIVE To assess survival, evaluate different prognostic factors that may affect disease-free survival (DFS) in Saudi patients after RC for carcinoma of the bladder and to compare our results with those of Western countries. DESIGN Retrospective chart review. SETTING A tertiary care center in Saudi Arabia. PATIENTS AND METHODS We collected data on patients who underwent RC for bladder cancer in the period between 1979 and 2014. Demographic, clinical and pathological variables and the application of perioperative chemotherapy were reviewed. Univariate and multivariate analyses were done with DFS as the end point. MAIN OUTCOME MEASURE Disease-specific survival. RESULTS On 328 patients for whom data was available, the median follow up was 23 months (range, 2 month–28 years) and median age was 58 years (range, 21–90). Of these patients, 268 were males (81.7%), 235 (71.7%) had urothelial carcinoma (UC), 79 (24.1%) had squamous cell carcinoma (SCC), and 208 (63.4%) had pathological tumor stage 3 or more. The 5-year overall survival (OS) and DFS were 52% and 48%, respectively. There was no statistically significant difference in DFS of patients with UC and pure SCC. On univariate analysis, lymph node status and pathological tumor stage were significant predictors of DFS. Both variables sustained statistical significance in a multivariate analysis. CONCLUSION Survival following RC is almost the same as others. Moreover, pathological tumor stage and lymph node metastasis were the only independent predictors for survival following RC. Future cooperative prospective studies are required to gain data on our region. LIMITATIONS Relatively small sample size and retrospective.