Malignant Peripheral Nerve Sheath Tumor: An Unusual Cause of Intussusception

Malignant peripheral nerve sheath tumors (MPNST) are defined as any tumor arising from a peripheral nerve or showing nerve sheath differentiation. The majority of these tumors arise on the trunk, extremities, or head and neck region. The literature to date has fewer than 14 cases of MPNST arising in the gastrointestinal tract, and only two cases were ever reported in the small intestine, one of which was a recurrent disease. In this paper, we report the first US case of an MPNST arising in the small intestine and presenting as intussusception.     

Adrenal Schwannoma Treated With Laparoscopic Surgery

Objective:

We report a case of left adrenal schwannoma in a 62-year-old man, incidentally discovered on an abdominal computed tomography. It was successfully treated with laparoscopic adrenalectomy.

Methods:

On admission, no remarkable findings were recognized in the patient''s blood and urine examination, including adrenal function. Laparoscopic left adrenalectomy was performed with the diagnosis of a nonfunctioning adrenal tumor.

Results:

Macroscopically, the tumor (45 mm × 30 mm, 60 g) arose from the medulla of the adrenal gland with a clear border distinguishing it from surrounding tissues. Histologically, the tumor consisted uniformly of spindle cells that were positive for S-100. The cortex was compressed but showed no atrophy. The diagnosis of adrenal schwannoma was made.

Conclusion:

Although an increasing number of adrenal incidentaloma have been identified with the recent advances in imaging techniques, only a few cases of schwannoma of the adrenal gland have been reported. We reviewed the cases reported previously in an attempt to reveal the characteristic features of this rare disease.     

Early results of bladder-cancer screening in a high-risk population of heavy smokers

OBJECTIVE

To report first results of an early bladder‐cancer detection programme, and to evaluate the detection rate and the diagnostic value of the tests used.

SUBJECTS AND METHODS

Urine samples of 183 screened subjects with a history of smoking of ≥40 pack‐years were collected for analysis with a urinary dipstick test for haematuria, the nuclear matrix protein‐22 test (BladderChek®, Matritech, Inc., Newton, MA, USA), voided urine cytology and a molecular cytology test (UroVysion, Abbott Molecular Inc., Des Plaines, IL, USA). Participants with at least one positive test result had a further evaluation including cystoscopy and radiological imaging. The subjects’ risk factors, test results and histological findings were analysed.

RESULTS

In all, 75 subjects had at least one positive test result and were evaluated further; abnormal histological findings were detected in 18 (24% of those who had cystoscopy, 9.8% of the original 183), 15 of those in the urinary bladder, with pTaG1 (one), carcinoma in situ (two), dysplastic lesions (11) and one an inverted papilloma. In the upper urinary tract, two urothelial tumours (pTaG1 and pTxN2G3) and one renal cell carcinoma (pT1G2) were detected by computed tomography. In summary, six of 183 subjects (3.3%) had a histologically confirmed malignant tumour and another 12 (6.6%) were identified with a possible pre‐cancerous lesion of the urinary tract. The urinary dipstick, BladderChek, cytology and UroVysion detected (i.e. were true‐positive in) nine (50%), one (6%), seven (39%) and 11 (61%) of the 18 tumours found, while they failed to detect nine (50%), 17 (94%), 11 (61%) and seven (39%) of these lesions, respectively. Omitting the urine dipstick test, the BladderChek, cytology or UroVysion from the test setting could have spared 40, five, two or one subjects(s) from unnecessary invasive interventions; however, three, none, two or six lesions, would have been missed. More positive screening tests per subject was associated with a higher probability of a (pre)‐malignant lesion.

CONCLUSION

Screening a high‐risk group with a history of smoking of ≥40 pack‐years showed a significant proportion (3.3%) with malignancy. These first results are encouraging and warrant continuation of the screening programme. In this series the most efficient screening tool was the combination of UroVysion, cytology and urinary dipstick testing. Of special scientific interest will be the follow‐up of those patients with a possible pre‐cancerous lesion.     

Free radical damage as a biomarker of bladder dysfunction after partial outlet obstruction and reversal

OBJECTIVE

To investigate the use of free‐radical generation as a result of protein carbonylation and nitrotyrosination to characterize the level of bladder dysfunction after partial bladder outlet obstruction (PBOO) and reversal.

MATERIALS AND METHODS

We surgically created PBOO in male New Zealand White rabbits; after 4 weeks of PBOO, one group of six rabbits was assessed, while the PBOO was relieved in two additional groups of six rabbits each that were assessed at 4 and 8 weeks after relieving the PBOO. Six sham‐operated rabbits served as controls. Sedated rabbits were assessed by cystometry and the bladders were then removed for contractile, histological and molecular studies. Western blotting was used to determine the level of carbonylation and nitrotyrosination at the protein level.

RESULTS

The PBOO group had significant decreases in the contractile responses to field stimulation, ATP, carbachol and KCl. The responses to all forms of stimulation increased significantly at 4 weeks after reversal, and further increased to near normal levels by 8 weeks. Similarly, compliance and cystometric values also returned to near normal values after reversal. The hypertrophied smooth muscle of the obstructed bladders regressed to near‐normal size. There was a significant increase in the level of carbonylation and nitrotyrosination after PBOO, and a progressive decrease in the 4‐week reversal groups, nearing control values by 8 weeks.

CONCLUSIONS

Significantly increased carbonylation and nitrotyrosination levels after PBOO correlated with the severe dysfunction in the obstructed rabbits. Similarly, decreased levels of oxidation and nitration correlated with the functional recovery after reversal.     

Does photodynamic transurethral resection of bladder tumour improve the outcome of initial T1 high‐grade bladder cancer? A long‐term follow‐up of a randomized study

OBJECTIVE

To evaluate, in a long‐term follow‐up of T1 high‐grade bladder cancer treated in a prospective, randomized trial, whether fluorescence diagnosis (FD) increases recurrence‐free survival (RFS) or reduces progression to muscle‐invasive stages.

PATIENTS AND METHODS

In all, 191 patients with suspected superficial bladder cancer were treated with transurethral resection under white light (WL) or with FD; 46 presented with initial T1 high‐grade BC (WL, 25; FD, 21). There were no differences in multifocality of tumours, concomitant carcinoma in situ or tumour size in either group.

RESULTS

Patients were followed for a median of 7.3 (WL) and 7.5 (FD) years to evaluate RFS. In the WL group there were 11, and in the FD group three, recurrent tumours of the same stage and grade. The RFS at 4 and 8 years was 69% and 52% in the WL, and 91% and 80% in FD group, respectively. With FD, the RFS was significantly longer according to Kaplan‐Meier analysis (P = 0.025). In the WL group, three (12%), and in the FD group four (19%) patients progressed to muscle‐invasive stages (≥ T2).

CONCLUSION

In initial T1 high‐grade bladder cancer, FD is significantly better than conventional WL transurethral resection for RFS. However, the progression rate to muscle‐invasive disease was not reduced by FD. Thus the clinical course (progression) of T1 high‐grade bladder cancer remains unaffected by FD.     

Surveillance of patients with bladder carcinoma using fluorescent in-situ hybridization on bladder washings

OBJECTIVES

To compare the sensitivity and specificity of the UroVysion^TM (Abbott Laboratories Inc., Downers Grove, IL, USA) fluorescent in‐situ hybridization (FISH) assay to that of urinary cytology obtained from bladder irrigation during cystoscopic surveillance in patients with bladder carcinoma.

PATIENTS AND METHODS

The medical records were retrospectively reviewed for 41 consecutive patients screened at the authors’ institution between August 2000 and December 2006 for recurrence of pathologically confirmed bladder cancer. All 162 cytology examinations and 141 FISH assay results obtained from bladder washing were included. Recurrence was determined by cystoscopy, bladder biopsy and upper‐tract imaging. Sensitivity, specificity, positive predictive and negative predictive values were assessed using a chi‐square distribution with one degree of freedom.

RESULTS

There were 24 men and 17 women (male to female ratio 0.59), the mean (range) age was 56 (33–73) years and the mean follow‐up 30 (2–57) months. At the initial diagnosis, 35 of the 41 patients (85%) had superficial tumours (stage ≤ T1), while six (15%) had muscle‐invasive tumours (stage ≥T2). Twenty‐six (63%) had low‐grade and 15 (37%) had high‐grade tumours. In 16 of 141 (11%) of the FISH assays and 16 of 162 (10%) of the cytological samples that were collected from bladder irrigations, there were too few cells for an adequate analysis. The FISH assay correctly correlated with subsequent cystoscopy, bladder biopsy or upper‐tract imaging in 110/125 (88%) cases but not in 15/125 (12%). Cytology correctly correlated with the subsequent evaluation in 112/146 (77%) cases but did not in 34/146 (23%). When the FISH was compared with cytology in this setting, the sensitivity was 77% (30/39) vs 74% (37/50; P > 0.1), the specificity was 93% (80/86) vs 78% (75/96; P < 0.01), the positive predictive value was 83% (30/36) vs 64% (37/58; P < 0.05), and the negative predictive value was 90% (80/89) vs 85% (75/88; P > 0.1), respectively.

CONCLUSION

The UroVysion FISH assay obtained from bladder washings during cystoscopic surveillance of patients with a history of bladder cancer provides a similar specificity but greater sensitivity than that of cytology for detecting bladder cancer recurrences. Given the better specificity and similar sensitivity of UroVysion compared with urine cytology obtained from bladder washings, a reasonable approach might be to use the UroVysion assay as the primary marker for recurrence, with urine cytology used as a complementary examination.     

A comparison of white-light cystoscopy and narrow-band imaging cystoscopy to detect bladder tumour recurrences

OBJECTIVE

To determine whether narrow‐band imaging (NBI) cystoscopy enhances the detection of non‐muscle‐invasive bladder tumours over standard white‐light imaging (WLI) cystoscopy, as surveillance WLI is the standard method used to diagnose patients with recurrent bladder tumours, but they can be missed by WLI cystoscopy, possibly accounting for early recurrences.

PATIENTS AND METHODS

We evaluated 427 patients for recurrent bladder tumours by WLI cystoscopy, followed by NBI cystoscopy as a further procedure, using the same video‐cystoscope. Recurrent tumours visualized by WLI or NBI cystoscopy were mapped, imaged, biopsied and subsequently treated by transurethral resection (TUR) or fulguration. Biopsies or TUR specimens obtained by WLI and NBI were examined separately for presence of tumour.

RESULTS

In all, 103 patients (24%) had tumour recurrences; 90 (87%) were detected by both WLI and NBI and another 13 (100%) only by NBI cystoscopy. NBI detected extra papillary tumours or more extensive carcinoma in situ in 58 (56%) patients found to have recurrences. The mean number of recurrent tumours visualized on WLI cystoscopy was 2.3, vs to 3.4 seen on NBI cystoscopy (P = 0.01).

CONCLUSION

NBI cystoscopy improved the detection of recurrent non‐muscle‐invasive bladder tumours over standard WLI cystoscopy.     

Pancreatic schwannoma: Report of a case

Among pancreatic neoplasms, pancreatic schwannoma is quite rare. We report a case of solitary pancreatic schwannoma, plus a literature review of this tumor. A 71-year-old woman was diagnosed by abdominal ultrasonography as having a pancreatic tumor and was hospitalized in our department at Kumamoto University Hospital on January 26, 2006. Abdominal computed tomography, magnetic resonance imaging, and endoscopic ultrasonography all showed this tumor, which was located in the body of the pancreas, to have cystic and solid components, and with a septum in the cystic part of the lesion. The tumor, preoperatively identified as a mucinous cystic neoplasm, was clearly separated from the normal pancreatic parenchyma. We performed a spleen-preserving distal pancreatectomy with a lymph node dissection on February 7, 2006. A histopathological examination of the resected specimen by means of hematoxylin and eosin revealed the tumor to consist of two parts: one with a compact spindle cell pattern (Antoni type A), and the other showing degeneration of fat (Antoni type B). We also found positive results for immunohistochemical staining for S-100 and vimentin. These findings confirmed the tumor’s classification as a pancreatic schwannoma.