Gleason Scoring Varies Among Pathologists and this Affects Clinical Risk in Patients with Prostate Cancer

AIMS

To investigate whether our practice of specialist review of all diagnostic biopsies was necessary to prevent misgrading of referred prostate cancer patients, and whether this misclassification, if any, would have resulted in misclassification of clinical risk grouping (Seattle Risk Grouping [SRG]) and subsequent treatment strategy and prognosis.

MATERIALS AND METHODS

Important prognostic indicators for prostate cancer include the presenting prostate-specific antigen (PSA), clinical stage and Gleason sum of the tumour. These three variables are incorporated into the SRG cohorts to establish treatment strategy. Patients with prostate cancer referred for brachytherapy had their prostate biopsies reviewed by a reference pathologist (PD) with a special interest in prostate cancer. We compared the agreement between the scoring of the referring pathologists with that of PD, and evaluated if any differences changed the SRG and therefore the clinical risk and treatment strategy for the patients.

RESULTS

In only 52% (43/83) of cases, was there total agreement between the two sets of pathologists. The inter-rater agreement was statistically 'fair' (unweighted kappa statistic 0.27). In 90% (36/40) of cases with disagreement, PD assigned higher Gleason sums. In 40% (16/40) of cases with disagreement, the change in Gleason sum altered the SRG; in one out of 16 cases, the SRG was downgraded from 'intermediate' to 'low' risk disease; in six out of 16 cases, it was upgraded from 'low' to 'intermediate' risk, and, in nine out of 16, from 'intermediate' to 'high' risk.

CONCLUSION

Our findings confirm previous reports of only limited correlation between pathologists in reporting Gleason sums. In this study, 19% (16/83) of cases had their grading changed to a level that altered clinical risk, almost always (94%; 15/16) to one that worsened prognosis. This would have significantly affected treatment strategy for these patients, and thus we recommend that all centres ensure accurate Gleason grading by the use of pathologists with special interests in prostate cancer.

Peritoneovenous shunting is an effective treatment for intractable ascites

AIM AND METHODS

A retrospective review was carried out of children undergoing peritoneovenous shunting for intractable ascites.

RESULTS

11 children, aged 3 months to 12 years (median 31 months) underwent peritoneovenous shunting over the past 17 years. The duration of ascites ranged from one month to 2.5 years (median two months). The primary pathology consisted of previous surgery in eight (three neuroblastoma, one renal carcinoma, one hepatoblastoma, one adrenal teratoma, one renal artery stenosis, and one diaphragmatic hernia), and cytomegalovirus hepatitis, lymphatic hypoplasia, and lymphohistiocytosis in one patient each. All patients had failed to respond to previous treatment including peritoneal drainage in six patients, diuretics in five, and parenteral nutrition in five. There were no intraoperative problems. Postoperative complications included pulmonary oedema in three patients, shunt occlusion in three, infection in two, and wound leakage in one. Ascites resolved after shunting in 10 patients. Five shunts were removed one to three years after insertion without recurrence of ascites. Three others are free of ascites with shunts in place for less than one year postoperatively. Three children died from their underlying disease: two after resolution of ascites (neuroblastoma) and one in whom the ascites failed to resolve (lymphohisticytosis).

CONCLUSIONS

Peritoneovenous shunting is an effective treatment for symptomatic intractable ascites in children (10 of 11 successful cases in this series). Elective removal of the shunt after one year is recommended.

Are we good at thromboembolic disease prophylaxis - an audit of the use of risk assessment forms in emergency medical admissions

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. Thromboprophylaxis is an effective strategy for VTE prevention in high-risk patients. An initial audit in our district general hospital trust showed poor adherence to the thromboembolic risk factors consensus group recommendations and so a risk assessment form (RAF) was devised. We present repeated audits to assess the RAF uptake and its effects on VTE thromboprophylaxis. We also present data analysing perceptions among doctors of the RAF and reasons for its poor completion. We provide compelling evidence that the RAF is an invaluable tool in the assessment of VTE thromboprophylaxis.

Therapy of testicular cancer: a surgeon's view

Treatment for metastatic testicular cancer has generally met greatest success when it has involved platinum-based chemotherapy and this is widely used for metastatic disease in most centers. However, surgical techniques should not be excluded. Retroperitoneal lymph node dissection has enabled a high cure rate to be achieved when used in conjunction with chemotherapy in patients with more advanced stage cancers.

Why does man have a quadratus plantae? A review of its comparative anatomy

Quadratus plantae is a muscle in the sole of the foot, typically originating from the calcaneus and inserting into the posterolateral surface of the tendons of flexor digitorum longus. It is implicated in heel pain, claw toe deformity and diabetic polyneuropathy. Phylogenetic considerations suggest that quadratus plantae is getting bulkier, implying its significance in human locomotion. Is it simply an accessory flexor that brings the line of pull of flexor digitorum longus in line with the long axis of the foot, as its name would suggest? We cite evidence from electromyographic studies that suggest it actually acts as a primary toe flexor in voluntary movements, being preferentially recruited over flexor digitorum longus. From comparative anatomical considerations it also seems likely that quadratus plantae is an intrinsic evertor of the foot. Eversion is an important evolutionary asset, especially in erect bipedalism. Human electromyographic experiments have yet to confirm this. However, they do suggest that quadratus plantae functions to resist extension of the toes during the stance phase of locomotion, which serves to increase the stability of the foot. Future electromyographic experiments may provide more information on the role of quadratus plantae in human locomotor evolution and in foot eversion in particular.

The risks and benefits of cyclo-oxygenase-2 inhibitors in prostate cancer: A review

Cyclo-oxygenase (COX), also referred to as prostaglandin (PG) endoperoxidase synthase, is a key enzymatic mediator in the production of arachidonic acids to PGs and eicosanoids. Two isoforms of COX exist, namely COX-1 and COX-2, which have distinct physiological functions and tissue distribution. Epidemiological studies suggest that regular consumption of aspirin and/or other non-steroidal anti-inflammatory drugs (NSAIDs), which inhibit COX, could notably reduce the risk of developing many cancers. COX-2 expression has been shown to increase in many cancers and cancer cell lines, including human prostate adenocarcinoma. COX-2 may also be upregulated in proliferative inflammatory atrophy (PIA) of the prostate, a pre-neoplastic lesion. The COX-2 pathway may therefore be a useful target for chemoprevention of prostate cancer, and there is much interest in exploring this with the use of COX-2 inhibitor drugs such as celecoxib. While there is concern regarding the cardiovascular toxicities of coxibs, there is no evidence that there is any increased risk with the use of celecoxib in the short-term neoadjuvant setting.

Why Do Orthopaedic Surgeons Ignore the Medial Patellofemoral Ligament?

The medial patellofemoral ligament (MPFL) is a condensation of the medial capsule of the knee joint. In the past two decades dissection studies have shown that it extends from the superomedial border of the patella to the femoral epicondyle, at or immediately above the adductor tubercle. MRI and operative studies have revealed that it is almost invariably damaged by lateral patellofemoral dislocation. Current surgical management of such dislocations may involve imbricating the torn medial capsule and parapatellar retinaculum back onto the medial border of the patella. If the medial patellofemoral ligament is torn at or near the femoral attachment, as the latest MRI and operative studies demonstrate it frequently is, then this medial reefing procedure will not be successful in restoring normal anatomy and function. Here we review the anatomy and function of the MPFL, its role in patellar dislocation and as well as surgical treatment for patellar dislocation.

Modulation of hepatocyte thiol content by medium composition: implications for toxicity studies

Toxicity of compounds requiring glutathione for detoxification, thiol content and synthesis were determined in 24-h rat hepatocytes cultured in medium containing different concentrations of the sulphur amino acids. Glutathione synthesis was determined following prior depletion of glutathione with diethylmaleate. L-15 medium, which has high levels of cysteine and methionine (1 mM of each), provided some protection against dichloroacetone, dibromopropanol and dichloropropanol toxicity, and had a small effect on increasing glutathione content and synthesis, relative to Williams' medium E (WE) which has low levels (less than 0.5 mM) of both amino acids. However, WE containing N-acetylcysteine (NAC) (1 mM final cysteine concentration), with or without methionine (final concentration 1 mM), was a better cytoprotectant medium than L-15, markedly reducing toxicity of all three compounds, and rapidly (within 1.5 h) increasing cellular glutathione content. WE supplemented with methionine alone stimulated glutathione synthesis after an initial lag phase, and protected cultures against dichloropropanol, but not dibromopropanol or dichloroacetone, both of which are highly reactive in these cultures. There was a clear association between glutathione content at early time points in culture and toxicity observed at later time points, and overall these results indicate that differences in culture medium composition can alter intracellular glutathione content and xenobiotic toxicity.