Josip Vukina

Preoperatively Misclassified, Surgically Removed Benign Renal Masses: A Systematic Review of Surgical Series and United States Population Level Burden Estimate

PURPOSE A significant proportion of renal masses removed for suspected malignancy are histologically benign with the probability inversely proportional to lesion size. To our knowledge the number of preoperatively misclassified benign renal masses treated with nephrectomy is currently unknown. Given the increasing incidence and decreasing average size of renal cell carcinoma, this burden is likely increasing. We estimated the population level burden of surgically removed, preoperatively misclassified benign renal masses in the United States. MATERIALS AND METHODS We systematically reviewed the literature for studies of pathological findings of renal masses removed for suspected renal cell carcinoma based on preoperative imaging through July 1, 2014. We excluded studies that did not describe benign pathology and with masses not stratified by size, and in which pathology results were based on biopsy. SEER data were queried for the incidence of surgically removed renal cell carcinomas in 2000 to 2009. RESULTS A total of 19 studies of tumor pathology based on size met criteria for review. Pooled estimates of the proportion of benign histology in our primary analysis (American studies only and 1 cm increments) were 40.4%, 20.9%, 19.6%, 17.2%, 9.2% and 6.4% for tumors less than 1, 1 to less than 2, 2 to less than 3, 3 to less than 4, 4 to 7 and greater than 7, respectively. The estimated number of surgically resected benign renal masses in the United States from 2000 to 2009 increased by 82% from 3,098 to 5,624. CONCLUSIONS These estimates suggest that the population level burden of preoperatively misclassified benign renal masses is substantial and increasing rapidly, paralleling increases in surgically resected small renal cell carcinoma. This study illustrates an important and to our knowledge previously unstudied dimension of overtreatment that is not directly quantified in contemporary surveillance data.

Metachronous Bilateral Testicular Leydig-Like Tumors Leading to the Diagnosis of Congenital Adrenal Hyperplasia (Adrenogenital Syndrome).

A 33-year-old male with a history of left testis Leydig cell tumor (LCT), 3-month status after left radical orchiectomy, presented with a rapidly enlarging (0.6 cm to 3.7 cm) right testicular mass. He underwent a right radical orchiectomy, sections interpreted as showing a similar Leydig cell-like oncocytic proliferation, with a differential diagnosis including metachronous bilateral LCT and metachronous bilateral testicular tumors associated with congenital adrenal hyperplasia (a.k.a. “testicular adrenal rest tumors” (TARTs) and “testicular tumors of the adrenogenital syndrome” (TTAGS)). Additional workup demonstrated a markedly elevated serum adrenocorticotropic hormone (ACTH) and elevated adrenal precursor steroid levels. He was diagnosed with congenital adrenal hyperplasia, 3β-hydroxysteroid dehydrogenase deficiency (3BHSD) type, and started on treatment. Metachronous bilateral testicular masses in adults should prompt consideration of adult presentation of CAH. Since all untreated CAH patients are expected to have elevated serum ACTH, formal exclusion of CAH prior to surgical resection of a testicular Leydig-like proliferation could be accomplished by screening for elevated serum ACTH.

Medical Management of Peyronie’s Disease: a 2014 Update

Peyronie’s disease (PD) is a connective tissue disorder characterized by the development of dense fibrous collagen plaque deposits in the tunica albuginea of the penis, resulting in curvature of the erection and sexual dysfunction. It is both a physically and psychologically devastating disorder that remains a considerable therapeutic dilemma due to incomplete characterization of its pathophysiology and the paucity of randomized controlled trials. Along with an underlying genetic predisposition, numerous studies have implicated pro-inflammatory cascades and oxidative stress in the development of PD. Medical therapies targeting these pathways can be partially effective at decreasing or inhibiting plaque formation and symptoms of PD. Such therapies include the broad categories of oral medication and vitamin supplements, intralesional injections, and penile traction. The recent FDA approval for intralesional collagenase clostridium histolyticum provides a significant advancement in the medical treatment of PD. In addition to highlighting the latest data supporting intralesional collagenase clostridium histolyticum, this update aims to review the most current literature on all of the available options for medical treatment of PD and to provide a practical approach to the clinical management of PD in the office setting.