Luiz Balthazar Saldanha

Adrenocortical tumors: results of treatment and study of Weiss's score as a prognostic factor

PURPOSE The differential diagnosis between benign and malignant adrenal cortical tumors circumscribed to the gland is controversial. One hundred and seven patients with adrenal cortex tumors (excluding those with primary hyperaldosteronism) were studied to assess the 5-year survival rate of adults, children, patients stratified by pathological stage, and patients stratified according to Weisss score of <3 or >3. METHODS The patients were evaluated both clinically and biochemically. One hundred and five patients underwent surgery and were classified pathologically as stages I, II, III, or IV. The tumors were weighed, measured, and classified according to Weisss criteria and divided into 2 groups: <3 and >3. RESULTS After 5 years, the survival rate was 77.5% for the whole group, 74.61% for the adults, 84.3% for the children, 100% for stage I, 83.9% for stage II, 33% for stage III, and 11.7% for stage IV groups. Additionally, after 5 years, 100% of the patients with tumors with Weisss score <3 were alive compared to 61.65% of those with Weisss score >3. The average weights of the tumors of score <3 and >3 were 23.38 g 41.36 g and 376.3 538.76 g, respectively, which is a statistically significant difference. The average sizes of tumors of Weisss score <3 and >3 were 3.67 2.2 cm and 9.64 5.8 cm, respectively, which is also a statistically significant difference. CONCLUSIONS Weisss score may be a good prognostic factor for tumors of the adrenal cortex. Additionally, there was a statistically significant difference between the average weight and size of tumors with benign behavior (Weisss score <3) and those with malignant behavior (Weisss score >3).

Carcinoma in diverticulum of female urethra.

A case of female urethral diverticulum is reported by the authors. It is a rare disease and about 31 cases have previously been described. An analysis is made in relation to the diverticulum of the urethra and to female urethral carcinoma. Emphasis is given on the semiology and the recently acquired diagnostic procedures, as these have led to an increased number of recognized cases. In the case presented, an extended resection and a definitive urinary derivation was performed, together with chemo- and radiotherapy. A follow-up of 2.5 years showed no signs of recurrence or metastases.

Ureteral necrosis in dermatomyositis.

We describe a child with dermatomyositis and calcified necrosis in the middle third of both ureters. Histopathological examination showed vasculitis associated with ureteral necrosis and calcification. These findings together with a similar previous report in the literature have prompted us to correlate dermatomyositis in childhood with ureteral necrosis and to anticipate specifically a lesion in the middle third of the ureter because of the relative lack of blood flow in that segment.

Urothelial carcinoma transmission via kidney transplantation

Transmission of urothelial carcinoma via solid organ transplant has never been reported in the literature to our knowledge. We report a case of transmission of this tumour to a kidney recipient. The donor was a 37-year-old woman, victim of a subarachnoid haemorrhage. The recipient was a 21-year-old girl, with a history of chronic kidney disease secondary to neurogenic bladder. This fatality has been rarely described in literature, but never with this histological type of cancer. Nowadays, with the expanded criteria for donation, older people are accepted as donor because of the shortage of organs. However, this may increase the likelihood of the number of cancer transmission.

Nodular diabetic glomerulosclerosis without diabetes mellitus.

A 66-year-old white man presented with severe chronic renal failure. He had no past or present symptomatic glucose intolerance nor a family history of diabetes mellitus. Several fasting plasma glucose determinations, hemoglobin Alc and an oral glucose tolerance test were normal. Funduscopic ophthalmoscopy and retinal fluorescein angiography did not demonstrate diabetic retinopathy. The kidney biopsy showed nodular diabetic nephropathy, with increased mesangial matrix, thickened glomerular basement membrane, and afferent and efferent glomerular arteriolar hyalinization. The diagnosis of nodular diabetic nephropathy was made in this patient in the absence of past or present or familial evidence of diabetes mellitus.

Tuberculosis in renal transplant patients

Tuberculose (TB) foi diagnosticada em 25 de 466 pacientes submetidos a transplante renal. A TB surgiu entre 1 mes e 9 anos pos-transplante. O pulmao foi acometido em 76% dos casos, isoladamente (56%), ou associado a outras localizacoes (20%). Os outros orgaos envolvidos foram: pele, articulacoes, testiculos, trato urinario, sistema nervoso central e linfonodos. O diagnostico foi confirmado por biopsia em 64% dos casos, pela identificacao do bacilo em 24% e apenas a necropsia em 12%. Tres formas histologicas foram identificadas: exudativa (nos casos de aparecimento precoce e de maior gravidade) granulomatosa (naqueles benignos e de aparecimento tardio) e mista (naqueles intermediarios). As doses de azatioprina foram constantes ao longo do periodo pos-transplante, tanto no grupo tuberculoso como no controle, bem como nos pacientes tuberculosos que faleceram e que se curaram. O numero de crises de rejeicao tratadas foi maior no grupo TB do que no grupo controle. As doses de prednisona e o numero de crises de rejeicao foram maiores nos pacientes tuberculosos que faleceram do que naqueles que sobreviveram. Quinze pacientes se curaram e 10 faleceram, oito de causas relacionadas a TB, Seis destes obitos ocorreram nos 6 primeiros meses pos-transplante. Em um paciente a TB foi transmitida pelo enxerto.

Comparison of palpation-guided and ultrasound-guided biopsies in transplanted kidneys

Biopsy is the gold standard for the diagnosis of conditions affecting the function of renal allografts. Obtaining representative tissue in biopsies is critical but these procedures are associated with up to 9% of complications and 20% of inadequate material. Although ultrasound guidance allows perfect control of depth and location of the graft, there is controversy regarding the cost–benefit of its use and reports of unsuitable material in ultrasound‐guided biopsies are still high. 
Purpose: To compare ultrasound with the palpation method to guide biopsies in order to see if there is any difference between both methods and which one is better. 
Patients and methods: The casuistic consisted of 82 renal transplant patients (32 female and 50 male patients, age ranging between 5 and 64 yr; m=31.2 yr) randomized into two groups: GI, palpation‐guided; GII, ultrasound‐guided. Fifty‐six biopsies were performed in GI and 66 in GII. 
Results: Number of glomeruli, arcuate, and interlobar arteries and arterioles were compared in the two groups and were 503 (m=10) vs. 801 (m=12.9), 24 (m=0.5) vs. 38 (m=0.6), 104 (m=2.1) vs. 154 (m=2.5), and 174 (m=3.5) vs. 264 (4.3), respectively (p<0.05). Inadequate material for analysis in GI and GII was 7.1 and 7.6%, respectively (p=0.72). 
Conclusions: Although ultrasound guidance improves the number of glomeruli, arcuate, and interlobar arteries, as well as arterioles, compared with palpation‐guided biopsies, there is no difference in the rate of adequate material between the two methods.

Acute vascular rejection: a clinical and morphological study

Abstract We analyzed one special type of acute vascular rejection (AVR), defined as fibrous thickening of the arterial intimal layer that leads to early renal failure. Twenty‐one patients who presented this histological pattern were studied among 339 transplanted over 4 years. Patients were separated into two groups. Thirteen patients have restained their kidneys (Group A, 61.9 %) and 8 have lost their grafts (Group B, 38 %). Diagnosis was made on average 430. POD in GA and at 49° POD in GB on the 43rd postoperative day in group A and on the 49th postoperative day in group B (NS). In group A, mean serum creatinine is 2.2 mg/dl and follow‐up time is 29 months. Oliguria was much more frequent in group B (75% versus 15.3%, P= 0.01). These patients were submitted to 91 renal biopsies always because of non‐function. Typical vascular lesions began at arcuate arteries and progressed, as seen in sequential biopsies, to interlobular arteries and arterioles. When only arcuate arteries were affected, 22.5 % of renal losses were seen, but when arcuate plus interlobular arteries were compromised, 72.2 % of patients lost their kidneys (P= 0.006). We did not identify any difference in immunofluorescent staining from biopsies with or without vascular rejection, or between groups A and B. We concluded that about 2.3 % of our patients lost their kidneys because of this kind of AVR, diagnosed near the 43rd postoperative day. The only clinical predictive sign of poor reversibility was oliguria. The attack on arcuate plus interlobular arteries meant a poor prognosis. Immunofluorescent staining did not have a prognostic value.

Renal leiomyosarcoma treated with partial nephrectomy

A 52-year-old woman of mixed white and negro blood,suffering from diabetes mellitus, arterial hypertension, andstable angina, was undergoing treatment with enalapril,atenolol, hydrochlorothiazide, metformin, and aspirin.There was no significant familial history of neoplastic dis-eases. The physical examination was unremarkable. Thecomplete blood count, blood biochemical values, and uri-nalysis were normal. She underwent magnetic resonance forassessment of the renal vessels, which were normal, though,incidentally, a 2-cm solid lesion was found in the left kid-ney (Fig. 1). The rest of the abdominal cavity was normal.A partial nephrectomy was undertaken by means oflumbotomy; the surgical specimen revealed a clearly de-fined solid nodule measuring 1.7 cm, surrounded by nor-mal renal tissue, which did not extend outside Gerota’s fas-cia (Fig. 2).The histopathological examination demonstrated a low-grade renal leiomyosarcoma with surgical margins that werenegative for neoplasia. The immunohistochemical profileshowed neoplasia of mesenchymal origin withmyofibroblastic muscular differentiation (Fig. 3).

Post‐transplant neutrophilic interstitial nephritis ‐ an important cause of graft dysfunction

Abstract Post‐transplant neutrophilic interstitial nephritis (NIN) is characterized by an interstitial infiltrate consisting of polymorphonuclear cells that leads frequently to acute graft dysfunction. In 220 graft biopsies performed because of renal dysfunction over 2 years in our unit, 11 (5 %) diagnoses of NIN were made. Only two patients had chronic pyelonephritis as original disease. Four patients had urological problems before transplantation. After transplantation, five patients had urinary tract infection, one had urethral stenosis, two had vesicourethral reflux and one patient had a perine‐phritic abscess. Seven patients had fever (63 %). Only in six patients did urine culture lead to microorganism isolation. After 6 months, only two patients had a serum creatinine level < 1.4 mg/dl, five patients had abnormal function, three had lost their grafts, and one patient had died with sepsis. We conclude that 5 % of the biopsies performed in our center disclosed NIN, an entity that causes graft dysfunction and progresses frequently to chronic renal failure. In some cases, no infectious etiology could be detected.