Ann E. Anderson

Epithelioid angiomyolipoma of the ovary: A case report and literature review

Angiomyolipoma (AML) is a benign mesenchymal neoplasm that mainly occurs in the kidney either sporadically or in patients with tuberous sclerosis complex (TSC). Extrarenal AML is uncommon. We describe a 39-year-old female with a history of TSC and bilateral multicentric renal AML who presented with a persistent cystic ovarian mass that fluctuated in size during 2 years of ultrasonographic observation before its removal by salpingo-oophorectomy. The 4.5-cm mass was solid and cystic and tan-yellow. Microscopic examination showed an admixture of epithelioid cells, smooth muscle bundles, large thick-walled blood vessels, and mature adipose tissue. The epithelioid cells had abundant eosinophilic cytoplasm and many had bizarre atypical nuclei including multinucleated forms. Mitoses were rare. Typical smooth muscle cells and the epithelioid cells were strongly immunoreactive for HMB-45. To our knowledge, this represents the first report of an AML arising in the ovary. The differential with other oxyphilic tumors of the ovary is discussed.

Laparoscopic ureteral reconstruction with small intestinal submucosa.

PURPOSE To evaluate the feasibility of laparoscopic ureteral reconstruction with small intestinal submucosa (SIS) in the pig ureter. MATERIALS AND METHODS Eight female pigs weighing between 25 and 30 kg were enrolled. After anesthesia was administered, a double-pigtail stent was inserted, the animals were moved to a lateral decubitus position, pneumoperitoneum was established, and three 10-mm ports were positioned. The ureter was opened longitudinally for 7 cm, and two thirds of the periphery of the upper third of the left ureter was excised. The SIS was anastomosed to the upper and distal ureteral segments with chromic 4-0 sutures. The double-pigtail stent was removed 6 weeks after the initial procedure, and retrograde pyelography was performed a week later to confirm the viability of the pelvicaliceal system. RESULTS The average duration of the procedures was 210 minutes (range 125-250 minutes). All animals survived the entire follow-up period of 7 weeks. Retrograde pyelography revealed a patent ureteral lumen, and no obstructive phenomena were observed. Histologically, the SIS-regenerated ureteral segments were remarkably similar to normal porcine ureters and were indistinguishable from neighboring tissue. CONCLUSION Laparoscopic ureteral reconstruction with SIS proved to be effective and technically feasible. The SIS seems to be an effective biodegradable scaffold, facilitating regeneration of host tissue.

Pneumoperitoneum with Carbon Dioxide Inhibits Macrophage Tumor Necrosis Factor-α Secretion: Source of Transitional-Cell Carcinoma Port-Site Metastasis, with Prophylactic Irrigation Strategies to Decrease Laparoscopic Oncologic Risks

PURPOSE Peritoneal macrophages play a critical role in maintaining local host resistance to infection and malignancy through the secretion of tumor necrosis factor-alpha (TNF-alpha). We hypothesized that attenuated TNF-alpha secretion, as a result of CO(2) pneumoperitoneum, could alter local immune surveillance, thereby contributing to the development of carcinomatosis and incisional metastasis. We further sought to determine if port-site metastasis could be prevented with prophylactic irrigants. MATERIALS AND METHODS C57BL/6 mice (n = 50) and the syngenic murine bladder tumor (MBT-2) cell line were used. Experiment 1: Mice were subjected to either CO(2) pneumoperitoneum at 6 mm Hg (n = 10) or a 3-cm midline incision (n = 10). Peritoneal macrophages (1 x 10(6)/animal) were collected and subjected to lipopolysaccharide challenge. TNF-alpha levels were quantified using the Quantikine Mouse TNF-alpha/TNFSF1A Immunoassay. Experiment 2: Peritoneal and port-site metastasis were evaluated 1 week after 1 x 10(6) MBT-2 cells/animal were spilled in an open group (n = 5) and through 5-mm trocars of a pneumoperitoneal group (n = 5). Experiment 3: 1 x 10(6) MBT-2 cells/animal were spilled intraperitoneally through 5-mm trocars of four groups (n = 20). Port sites in each group were then irrigated with either sterile water, mitomycin C (1.0 mg/mL), betadine (10%), or heparin (1000 U/mL). At 1 week, incisional sites were evaluated for gross and microscopic metastasis. In each experiment, Student t-test was used to quantify statistical differences. RESULTS Peritoneal macrophage TNF-alpha secretion was significantly inhibited in mice subjected to CO(2) pneumoperitoneum v control at 10 and 20 minutes (P = 0.015, P = 0.001, respectively). When 1 x 10(6) MBT-2 cells were spilled, a significantly higher average tumor burden developed in animals subjected to CO(2) pneumoperitoneum than in controls at 1 week (9.2 gm v 3.8 g, P = 0.002). All irrigants prevented the development of port-site metastasis, yet sterile water did so without toxic effect. CONCLUSION In a syngenic murine model, CO(2) pneumoperitoneum causes inhibition of peritoneal macrophage TNF-alpha secretion. Heavier intraperitoneal and incisional metastasis develops in C57BL/6 mice subjected to CO(2) pneumoperitoneum and a tumor challenge with 1 x 10(6) MBT-2 tumor cells compared with open controls. Inhibition of peritoneal macrophage TNF-alpha secretion may be considered an adverse event contributing to the development of transitional-cell carcinoma (TCC) port-site metastasis, especially if surgical oncologic principles are violated. Irrigating trocar sites and the peritoneal cavity with sterile water at the conclusion of laparoscopic nephroureterectomy and laparoscopic radical cystectomy may offer a safe prophylactic strategy to prevent this unfavorable event. Our murine model presents a novel avenue for the development of adjunct immunomodulatory therapies to perhaps further reduce oncologic risks during laparoscopic management of TCC.

Utilization and cancer detection by U.S. prostate biopsies (2005-2011).

107 Background: To assess the positive biopsy rate and core sampling pattern in patients undergoing prostate biopsy in the US at a national reference laboratory and pathology laboratories integrated into urology group practices and analyze the relationship between positive biopsy rates and number of specimen vials per biopsy (sv/b). METHODS For the years 2005-11, we collected pathology data from a national reference laboratory (NRL) including number of urologists and urology practices referring samples, total specimen vials submitted per prostate biopsy, and final diagnosis for each case. The diagnoses were categorized as benign, malignant, prostatic intraepithelial neoplasia or atypical small acinar proliferation. Over the same period, similar data was gathered from urology practices with in-house laboratories performing global pathology services (urology practice labs, UPL) identified by a member survey of the Large Urology Group Practice Association. For each year studied, positive biopsy rate and number of specimen vials/biopsy were calculated in aggregate and separately for each site of service. RESULTS From 2005-11, 437,937 biopsies were submitted in 4,230,129 vials (9.4 sv/b); overall positive biopsy rate was 40.3%, identical at both the NRL and UPL (p=0.97). Nationally, the number of specimen vials/biopsy increased sharply from a mean of 8.8 during 2005-8 to 10.3 from 2009-11 (difference 1.5 sv/b, p=0.03). For the most recent 3 year period (2009-11), there was no significant difference between the NRL (10.0 sv/b) and UPL (10.6 sv/b) (p=0.08). Positive biopsy rate correlated strongly (p<0.01) with number of specimen vials/biopsy. CONCLUSIONS The positive prostate biopsy rate of 40.3% is identical across sites of service. Although there was a national trend towards increased specimen vials/biopsy from 2005-11, from 2009-11 there was no significant difference in specimen vials/biopsy across sites of service. Increased cancer detection rate correlated significantly with increased number of specimens examined. Segregation of prostate biopsy cores into 10-12 unique specimen vials has been adopted by urologists across sites of service and can be considered the de facto national standard of care.