Probability of prostate cancer as a function of the percentage of free prostate-specific antigen in patients with a non-suspicious rectal examination and total prostate-specific antigen of 4–10 ng/ml

Our aim was to assess the usefulness of measuring the percentage of free prostate specific antigen (PSA) in serum in relation to reducing the number of prostate biopsies in men with benign prostate examinations and serum PSA levels between 4 and 10 ng/ml. The percentage of free PSA (Immulite) in serum was analyzed prospectively in 500 men, all of whom underwent ultrasound-guided sextant prostate biopsies. Cancer was detected in 21.4% (107/500) of the patients. Using a free PSA cutoff of < or = 23% as a criterion for performing prostate biopsy would have detected 94.4% of cancers, avoided 18.8% of benign biopsies and yielded a positive predictive value of 25.3%. The percentage of free PSA increased with prostate volume. Mean total PSA and mean free percent PSA values increased as patient age increased, influencing the calculation of cutoff values, sensitivity and specificity. PSA density had a sensitivity and specificity not significantly different than the percentage of free PSA. Measurement of the percentage of free serum PSA improves the specificity of prostate cancer detection in patients with elevated total serum PSA levels and benign prostate examinations.

[Acute renal failure caused by cholesterol embolism in kidney transplantation from cadaver donor. Is the prognosis more favorable than in native kidneys?]

We present the case of a 47 years old women with a third cadaveric kidney transplant. After surgery, she had effective diuresis reaching a serum creatinine of 2.2 mgs% at 19 postoperative day. In the nest few days, the patient was oliguric with worsening of renal function. The ultrasound examination excluded urinary obstruction. With the suspicion of acute rejection, a renal biopsy was performed. The histopathological record disclosed cholesterol emboli with a widespread multifocal ischemic infarct and eosinophilic tubulointerstitial nephritis. The renal function deteriorated in the seven next days and peritoneal dialysis was carmedow. She then recovered diuresis with improvement of renal function, reaching at discharge a serum creatinine of 1.8 mgs%. The renal function remains stable after 3 years. We analysed the etiopathogenic factors of this disease and the possible beneficial effects of immunosuppresive drugs in better prognosis compared with the same entity in native kidneys.

[Recurrence and spontaneous remission of nephrotic syndrome in secondary renal amyloidosis]

Secondary systemic amyloidosis (AA) occurs in association with chronic inflammatory disorders and chronic infections. Regression can occur after therapeutically induced remission of the underlying disease; spontaneous remissions has been reported infrequently. We report a 61 year-old woman, with antecedent pulmonary tuberculosis, who developed a nephrotic syndrome at the time of a respiratory infection. Renal biopsy showed secondary amyloidosis. Remission in the nephrotic syndrome appeared spontaneous, but it recurred in the course of pneumonia, and had a second spontaneous remission a maintained at present.

[Simultaneous presence of antibodies against the glomerular basement membrane and anti-myeloperoxidase antibodies in 2 patients with rapidly progressive glomerulonephritis]

We report two patients with rapidly progressive glomerulonephritis without alveolar hemorrhage. Renal biopsy showed extracapillary glomerulonephritis with linear deposits of immunoglobulin G. Serologically anti-glomerular basement membrane antibodies (Ac AMBG) and ANCA anti-myeloperoxidase were present. All patients were treated with steroids, cyclophosphamide and plasma exchange. One patient needed dialysis, and other one died from a renal biopsy complication. We discuss the epidemiologic, pathogenic and prognostic aspects of this association.

[Idiopathic membranous nephropathy in an elderly patient with type 2 diabetes mellitus]

We report an 85 years-old patient with type 2 diabetes mellitus and both clinical and biochemical nephrotic syndrome. The renal biopsy showed membranous nephropathy at stage I-II. There was no evidence of malignancy. The patient was treated with steroids, and two months later the proteinuria had not improved. The objects under discussion are the factors that should lead to suspect the existence of glomerulonephritis, other than diabetic glomerulosclerosis, suggesting the need for kidney biopsy. We also focus on the prognostic and therapeutic relevance, as well as on the common pathogenic aspects.

[Progressive systemic sclerosis associated with anti-myeloperoxidase ANCA vasculitis with renal and cutaneous involvement]

Sclerodema renal crisis is the usual form of presentation of renal disease in systemic sclerosis. We report a woman who at age 63 was given a diagnosis of scleroderma with Raynaud's phenomenon and cutaneous, oesophageal and lung involvement but no evidence of renal disease and no treatment with D-penicillamine. Two years later she developed progressive renal failure, nephrotic range proteinuria, haematuria and the presence of serum MPO-ANCA; she was normotensive. Renal biopsy revealed extracapillary and necrotizing glomerulonephritis and skin biopsy showed leucocytoclastic vasculitis. This clinical picture was compatible with necrotizing vasculitis of the microscopic polyarterits type. After treatment with pulse steroids followed by oral steroids and monthly intravenous cyclophosphamide her renal function stabilised and the serum MPO-ANCA disappeared.

Determination of the percentage of free prostate-specific antigen helps to avoid unnecessary biopsies in men with normal rectal examinations and total prostate-specific antigen of 4-10 ng/ml

OBJECTIVE

To assess the usefulness of measuring the percentage of free prostate-specific antigen (PSA) in serum to reduce the number of prostate biopsies in men with serum PSA levels between 4 and 10 ng/ml and benign prostate examinations.

MATERIALS AND METHODS

The percentage of free PSA (Immulite((R))) in serum was analyzed prospectively in 180 men with benign digital rectal examinations and total PSA serum levels of between 4 and 10 ng/ml. All patients underwent ultrasound-guided sextant prostatic biopsies. Sensitivity, specificity and positive and negative predictive values were calculated as well as the percent of patients in which biopsies could have been avoided for various cutoff values of the percentage of free PSA as an indicator for biopsy. Influence of age in the determination of cut points was evaluated.

RESULTS

Cancer was detected in 22.2% (40/180) of the patients. Mean percentage of free PSA was 13.4% in patients with cancer and 18.9% in patients with benign prostatic hyperplasia (p = 0.001). Using a percentage of free PSA cutoff of 22% or less as a criterion for performing prostatic biopsy would have detected 95% of cancers, avoided 25% of benign biopsies and yielded a positive predictive value of 29% in patients who underwent biopsy. Mean percent of free PSA values increased as mean subject age increased, influencing the calculation of cut points, sensitivity and specificity. Leaving the cut point constant across all age groups will oblige older patients to undergo an increased number of unnecessary biopsies, although allowing for higher sensitivity in younger men.

CONCLUSIONS

Measurement of the percentage of free serum PSA improves specificity of prostate cancer detection in patients with elevated total serum PSA levels and benign prostate examinations. Subject age seemed to influence the determination of optimal cut points.

Immunocytochemical electron microscopic study and Western blot analysis of caldesmon and calponin in striated muscle of the fruit fly Drosophila melanogaster and in several muscle cell types of the earthworm Eisenia foetida

Caldesmon and calponin are two proteins that are characteristic of vertebrate smooth muscle. In invertebrates, caldesmon has only been studied in some molluscan muscles, and no previous references to calponin have been found. The aim of this paper was to investigate the presence and distribution of caldesmon and calponin in several invertebrate muscle cell types, classified according to their ultrastructural pattern: transversely striated muscle (flight muscle from Drosophila melanogaster), obliquely striated muscle (muscular body wall and inner muscular layer of the pseudoheart from the earthworm Eisenia foetida), and a muscle of doubtful classification which seems to be intermediate between smooth muscle and obliquely striated muscle (outer muscular layer of the pseudoheart, from E. foetida), using electron microscopy immunocytochemistry and Western blot analysis. Immunoreactions to both caldesmon and calponin were observed in the outer muscular layer cells from the earthworm pseudoheart but neither in the transversely striated muscle of D. melanogaster nor in the obliquely striated muscle from the earthworm. Present findings suggest that caldesmon- and calponin-like proteins are also present in invertebrate muscle cells, but only in those that are ultrastructurally similar to the vertebrate smooth muscle cells. Since discrepancies in the classification of some invertebrate muscles are common in the literature, the use of distinctive markers, such as troponin, caldesmon and calponin may improve our understanding of the nature and properties of many invertebrate muscles showing an ultrastructural pattern that does not resemble any of the classic muscle types.

Neural variant of fetal rhabdomyoma and naevoid basal cell carcinoma syndrome

A 15-year-old boy with the characteristic features of the naevoid basal cell carcinoma syndrome presented with a retroperitoneal mass. The tumour showed morphological features of a still ill-defined variant of fetal rhabdomyoma, characterized by well-differentiated nerve fibres admixed with immature striated muscle cells, similar to neuromuscular choristoma. Four cases of fetal rhabdomyoma and naevoid basal cell carcinoma syndrome have been previously reported. The behaviour of this tumour has been benign, although a complete excision was impossible due to its close relation with abdominal vascular trunks.

Primary renal angiosarcoma. Case report and review of the literature

Primary angiosarcoma is one of the rarest kidney tumors. Only six satisfactorily documented cases have been reported in the literature. A new case is described. The tumour is usually in an advanced clinical stage when detected, and generally first presents with local pain and no urinary symptoms.

Systemic polyarteritis nodosa as the initial manifestation of a gastric adenocarcinoma

We report a case of systemic polyarteritis nodosa (PAN) leading to the discovery of an as yet asymptomatic, surgically curable gastric adenocarcinoma. PAN is rarely associated with malignancies and in such cases these are more often malignant haematological diseases than solid neoplasms. The immunopathological findings, the temporal relationship between both conditions, and the spontaneous resolution of vasculitis after tumour removal suggest a paraneoplastic origin of the systemic angitis.

[Multilocular cystic renal adenocarcinoma]

On detecting a complex cystic renal mass, we are faced with the problem of making the differential diagnosis from a variety of diseases, some of very distinct nature and prognosis. Surgical exploration may occasionally be warranted to make the diagnosis since no radiological or analytical method, including cytological analysis of its content, is absolutely reliable. A 46-year-old male patient with multicystic renal adenocarcinoma is described. We discuss the diagnostic and therapeutic dilemmas that arise on detecting a multilocular renal mass in an adult patient.

[Necrotizing vasculitis in the bladder]

The necrotizing lesion that affects the small and medium-sized arteries, commonly known as polyarteritis nodosa (PAN), usually have a systemic and variable involvement. Urothelial involvement at the level of the two ureters has been rarely described. We report a case of necrotizing vasculitis localized to the bladder that had manifested clinically as gross hematuria.

Hereditary nephropathy associated with hyperuricemia and gout

BACKGROUND

The clinical characteristics of hereditary nephropathy associated with hyperuricemia or gout have not been fully described, and the pathogenetic role of increased serum urate concentration is controversial.

METHODS

We examined the clinical characteristics of 14 patients and purine metabolism of seven patients, while they were on a purine-restricted diet, in two families with hereditary nephropathy associated with asymptomatic hyperuricemia or gout. Results of plasma and urinary purine measurements were compared with those obtained in 25 patients with gout and renal insufficiency and in 25 normal subjects. Eight subjects in both families were followed up for a mean of 44 months. Allopurinol was given to all patients and enalapril maleate to hypertensive subjects.

RESULTS

All patients had some combination of hyperuricemia, gout, renal insufficiency, arterial hypertension, and reduced kidney size. Decreased glomerular filtration rate was proportional to the decreased renal plasma flow. Renal vascular resistance was markedly increased in the patients with diminished renal plasma flow. All patients with familial nephropathy showed diminished urinary uric acid, hypoxanthine, and xanthine excretion rates. Purine under-excretion was more severe in affected patients with familial nephropathy than in patients with gout and renal insufficiency. Kidney biopsy specimens from three patients with familial nephropathy showed tubulointerstitial lesions and ischemic changes in glomeruli but no uric acid crystals. The kidney uric acid content was normal. Allopurinol treatment normalized serum urate levels, but serum creatinine concentrations increased and creatinine clearance decreased in all patients with familial nephropathy. One patient with gout only at initial evaluation developed renal failure during the follow-up period.

CONCLUSIONS

Increased serum urate concentrations in hereditary nephropathy associated with hyperuricemia and gout are due to severe impairment of uric acid excretion. Hyperuricemia does not appear, however, to be of pathogenetic relevance and may be a consequence of a primary disruption of renal hemodynamics.

[Waldenström's macroglobulinemia, cryoglobulinemia type I and membranous glomerulonephritis]

Renal complications in Waldenström's macroglobulinemia (WM) are infrequent and are characterized by the presence of PAS positive amorphous hyaline deposits in the capillary lumen, infiltrated with lymphoplasmatic cells with PAS positive inclusions in the interstices and intratubular hyaline cylinders. Membranous glomerulonephritis may be a paraneoplastic manifestation of the lymphoproliferative processes. A 67-year-old male was diagnosed of WM, type-I cryoglobulinemia with renal insufficiency without proteinuria. Renal histological examination revealed changes characteristic of nephropathy associated to WM as well as membranous glomerulonephritis. This association has not been described previously. The coexistence of two pathogenic mechanisms with a common base, lymphoproliferative disease, may explain this association.

[Multilocular renal cyst: clinico-pathological considerations apropos of a case and review of the literature]

A case of multilocular renal cyst (MRC) is reported in a hypertensive patient in whom the IVP had disclosed a left renal mass. The ultrasound and CT workup revealed a well-defined, solid renal mass that was angiographically hypovascular. Cytologic examination of the specimen obtained by fine needle aspiration biopsy yielded no conclusive data. A left radical nephrectomy was performed. The histologic diagnosis was that of multilocular renal cyst. At 42 months the patient remains hypertensive with no evidence of tumor recurrence. We discuss the diagnostic criteria of MRC and the difficulty in making the differential diagnosis from renal carcinoma, and describe the histologic features of MRC that permit us to distinguish this disease entity from other renal tumors or dysplastic disease with different biologic significance.

Polyarteritis nodosa and necrotizing glomerulonephritis associated with long-standing silicosis

A 55-year-old white male, with silicosis diagnosed 10 years earlier, presented massive proteinuria with microscopic hematuria, moderate renal failure and distal polyneuropathy. Bilateral renal angiography showed multiple intraparenchymal saccular aneurysms. Renal biopsy disclosed a focal segmental necrotizing glomerulonephritis and arteriolitis. After combined corticosteroid and immunosuppressive treatment, renal function improved and remained stable 6 months later.

Glomerular nephropathy associated with chronic Q fever

Of three patients with Coxiella burnetii endocarditis, two developed focal segmental proliferative glomerulonephritis (GN), and the third developed diffuse intracapillary proliferative glomerulonephritis. In one case, a good therapeutic response was followed by partial remission of the renal alterations, but 10 months later there were clinical and histological signs of active glomerular nephropathy, suggesting that the antigenic stimulus persisted. In another case, poor evolution of the infection was accompanied by clinically and histologically aggressive glomerular nephropathy, and advanced renal failure. The third patient, who had diffuse proliferative glomerulonephritis, underwent renal biopsy earlier than the other two cases, and the behavior of the nephropathy has not been aggressive to date. Immunohistopathologic study revealed a diffuse granular deposit of IgM and C3 in all three cases; the first two also presented a discrete linear IgG deposit in the capillary loops. Attempts to identify C burnetii antigen at the glomerular level by immunohistologic techniques failed in two patients. The literature on the association of chronic Q fever with glomerulonephritis is briefly reviewed.

Spontaneous regression of pulmonary metastases and long-term survival of a patient with metastatic renal cell carcinoma, after immunostimulation with bacillus Calmette-Guérin and extirpation of brain and contralateral lung metastases

A 52-year-old patient underwent left radical nephrectomy for renal cell carcinoma and received adjuvant chemotherapy postoperatively with adriamycin and 5-fluoruracil. Twenty months afterwards he developed cerebral and multiple bilateral pulmonary metastases. The cerebral metastasis was excised and nonspecific immunostimulation with bacillus Calmette-Guérin was initiated. Two years later the other secondaries had scarcely grown and extirpation of the two right pulmonary metastases was undertaken. Few months afterwards the two left pulmonary nodules disappeared. The patient continues free of disease more than 5 years after nephrectomy and 16 months after regression of the lung metastases.

Idiopathic IgA nephropathy presenting as malignant hypertension

Three cases are reported of idiopathic IgA nephropathy (Berger's disease) presenting as malignant hypertension, with no data suggesting the underlying glomerulopathy, which was uncovered only after renal biopsy was performed. Comments are made on the validity of the pathological diagnosis, the possible pathogenetic sequence of the association, and on the eventual risks and benefits derived from performing renal biopsy in such patients.

[Fetal rhabdomyomatous nephroblastoma: study of 2 cases and review of the literature]

Report of two cases of Fetal Rhabdomyomatous Nephroblastoma, a cytodifferentiated variant of Wilms' tumor. The incidence of this rare variant is of 2.10% in our material (88 nephroblastomas in a sixteen years period). The patients were ten months and two years old. Bilateral tumors were discovered in both patients. Preoperative radiotherapy was given but no reduction of the tumors size was obtained. Microscopically, benign looking striated muscle is the predominant component of the tumors, with scare foci of epithelial elements. The low age of presentation, high incidence of bilaterality and the peculiar intrapelvic renal growth are three relevant characteristics in the 35 cases previously reported as well as in these two new cases, that distinguish Fetal Rhabdomyomatous Nephroblastoma from conventional Wilms' tumor.

[Vitamin D3 poisoning and irreversible sequela]

Twenty-four children with vitamin D intoxication and a follow-up of one to thirteen years old (means: four years and seven months) are reviewed. Over-dosage was prescribed by medical order in 66.6% of patients and by the mother herself in 16.6%. Intensity of clinical symptoms (renal, neurologic, digestive) were related with daily dose administered whilst final secuelae depends on duration of overdosage. Hipercalcemia was easily corrected by association of low calcium diet, corticoesteroids and/or furosemide in least than a month in 81% of cases. Two patients died during the acute fase and 22.7% remain with permanent damage (five in chronic renal failure, one in haemodialysis and three with low IC).

Testicular and epididymal involvement in Fabry's disease

Autopsy specimens of the testes and epididymis of a 32-year-old male with Fabry's disease were studied by light and electron microscopy. The characteristic ceramide deposits (lamellar inclusions, myeloid-bodies, zebra-bodies) were found in the Leydig cells as well as in the epithelial lining of both the ductuli efferentes and the ductus of the epididymis. Similar myeloid-bodies were observed in the blood vessels, connective tissue cells and muscle cells of the testicular interstitium, tunica albuginea and epididymis. In contrast, myeloid-bodies were absent or scarce in both the seminiferous epithelium and the mediastinum testis. However, the seminiferous tubules were severely affected showing reduced diameter, thickening of the tunica propria, and a few degenerated spermatogonia and primary spermatocytes. The different degrees of involvement of the testicular structures might be related to their different functions, the absorptive and permeable structures being the most severely affected. The development of testicular alterations seems to have been slow, since the patient fathered three children.