Low AUA symptom score independently predicts positive prostate needle biopsy: results from a racially diverse series of 411 patients

OBJECTIVES

To evaluate the prebiopsy parameters, including the American Urological Association symptom score (AUASS), that may be predictive of positive biopsy. Transrectal ultrasound (TRUS) biopsy of the prostate represents the reference standard in the diagnosis of prostate cancer.

METHODS

A total of 411 consecutive men undergoing TRUS biopsy were prospectively evaluated. The indications for biopsy were abnormal digital rectal examination (DRE) findings and/or an elevated prostate-specific antigen (PSA) level. A single surgeon (C.R.P.) examined all the men. DRE and TRUS were each given a level of suspicion between 1 (low suspicion--smooth DRE, homogeneous TRUS) and 5 (high suspicion--hard DRE, hypoechoic lesion). A level of suspicion of 3 or greater was considered abnormal. The prebiopsy parameters examined included PSA level, age, race, biopsy history, prostate volume, TRUS-detected lesion, and AUASS.

RESULTS

Of 411 men, 62% were African American and 38% were white. The mean PSA level was 11.6 ng/mL. The mean patient age was 65.3 years. Overall, 39% of men had abnormal DRE and 32% abnormal TRUS findings. The mean AUASS was 9.3. The positive biopsy rate was 40.8%. Univariate analysis demonstrated that age, PSA level, prostate volume, abnormal DRE findings, TRUS-detected lesion, and AUASS (less than 7, low) were all predictive of a positive biopsy (P <0.05). Race was not statistically significant (P = 0.38). Detailed analysis of the AUASS in the 411 men indicated that 41% had low symptom scores (less than 7), 32% had moderate scores (8 to 19), and 27% had severe scores (20 to 35). In the group of men with low symptom scores (n = 169), univariate analysis demonstrated that age, PSA level, prostate volume, and abnormal TRUS findings were all statistically significant predictors of positive biopsy (P <0.05). Multivariate analysis of the data from the 411 men demonstrated that age, PSA level, prostate volume, abnormal DRE findings, and low AUASS were all independent predictors of positive biopsy (P <0.05).

CONCLUSIONS

In this prospective study, the independent predictors of positive TRUS biopsy included age, PSA level, prostate volume, abnormal DRE findings, and low AUASS. A low AUASS may be an important variable to consider when counseling patients before biopsy and when designing patient algorithms for prostate biopsy.

[Management of non-palpable breast lesions with vacuum-assisted large core needle biopsies (Mammotome). Experience with 560 procedures at the Val d'Aurelle Center]

Percutaneous vacuum-assisted large core needle biopsy of breast microcalcifications is now commonly performed as the initial approach to nonpalpable breast lesions. It can obviate the need for surgery in women with benign lesions and often lead to a one-stage surgical procedure when malignant lesions are diagnosed. To illustrate this strategy, we describe our experience based on 560 procedures performed within a 36 Month-period. Sixty percent of the lesions were benign, mostly fibrocystic changes. Thirty percent of the specimens were malignant, almost exclusively intraductal carcinomas, sometimes associated with an invasive component. This component must be identified by the pathologist in order to avoid incomplete treatment and to plan lymph node excision. Finally, 10% of the specimens were boderline including lobular neoplasia, atypical ductal hyperplasia and columnar cell lesions with atypia. Surgical excision is recommended for atypical ductal hyperplasia, columnar cell lesions with atypia and lobular neoplasia with particular features, pleomorphic or comedo-like, to avoid missing more aggressive associated lesions. A strict procedure is required for the analysis of needle core biopsies and the subsequent surgical specimens, to accurately classify breast lesions provided by a mammographic screening program. This procedure should be based on a multidisciplinary approach and dialog.

Prostate biopsy

Transrectal ultrasound guided (TRUS) prostate biopsies is the standard method in the diagnosis of prostate cancer. The use of prostate specific antigen (PSA) and digital rectal examination for prostate cancer screening has led to a dramatic increase in the number of TRUS guided biopsies. Frequently urologists are faced with the dilemma of treating a patient with a high suspicion of prostate cancer, but an initial set of negative biopsies. In this review we focus on the current knowledge of prostate biopsies, the indication to perform a biopsy, the impact of prostate volume in the number of cores taken, the technique of an initial and repeat biopsies and when to stop.

Bronchial cytology in pleural mesothelioma. A report of 3 positive cases, including 1 diagnosed initially on bronchial brushings

OBJECTIVE

To evaluate retrospectively the value of bronchial aspiration cytology in patients with histologically proven pleural mesothelioma, reappraising positive smears in light of conventional microscopic features and, when feasible, immunocytochemical investigations.

STUDY DESIGN

In 3 cases of mesothelioma with bronchial brushings positive for malignant cells, the cytologic features were correlated with the histologic findings.

RESULTS

Salient microscopic features included scant to moderate cellularity arranged in micropapillary clusters, morular aggregates with scalloped borders and isolated malignant cells. Intercellular clear spaces or windows suggesting a brush border on cell membranes were also noted. In cases with available material, immunocytochemistry was positive for keratins, epithelial membrane antigen and calretinin and negative for carcinoembryonic antigen. All the cases were histologically confirmed epithelial mesotheliomas.

CONCLUSION

In rare cases, pleural mesothelioma cells are shed within the airway lumina and can be detected in bronchoscopic cytology specimens. Cytologic features seem comparable to their analogues in pleural effusions. Although no single criterion appears diagnostic, their combined documentation could ensure correct interpretation, especially if supported by a limited immunocytochemical panel.

[Clinical experience with percutaneus large-core needle biopsies of the breast and evaluation of cytopathological and histopathological results]

OBJECTIVE

Core needle biopsy (CNB) allows a microinvasive diagnosis of breast lesions. We investigated whether imprint cytology of CNB specimens is a useful method of rapidly obtaining additional diagnostic information.

MATERIAL AND METHOD

During five years 46 218 breast examinations for 23 300 patients were performed. 563 patients were examined by CNB. The results of imprint cytology were compared with the histopathological results. Statistical analysis was done for all patients who underwent subsequent surgery.

RESULTS

195 of 563 patients were treated surgically. 155 patients exhibited malign lesions. 40 patients showed benign breast lesions. Four patients with malign findings in imprint cytology and histopathology of CNB were treated conservatively. Imprint cytology had a sensitivity of 0.89, specificity of 0.88, positive predictive value of 0.96 and negative predictive value of 0.67. Histopathology revealed a sensitivity of 0.90, specificity of 0.95, positive predictive value of 0.98 and negative predictive value of 0.70. 364 patients with benign findings in imprint cytology and histopathology were controlled subsequently. One of these patients developed five month later an invasive ductal tumor.

CONCLUSION

Imprint cytology of CNB is a reliable method to obtain additional diagnostic information. Inadequate and suspicious cases should be evaluated based on complementary diagnostic procedures for breast lesions.

No Increased Prostate Cancer Incidence After Negative Transrectal Ultrasound Guided Multiple Biopsies in Men with Increased Prostate Specific Antigen and/or Abnormal Digital Rectal Examination

PURPOSE

We investigated the incidence of prostate cancer after negative transrectal ultrasound (TRUS) guided multiple biopsies. Our secondary aim was to calculate the sensitivity of the extended protocol used.

MATERIALS AND METHODS

A cohort of 547 men with elevated prostate specific antigen and/or abnormal digital rectal examination but with results negative for prostate cancer on a mean of 9 TRUS guided biopsies was followed through record linkage to the national cancer Registry. The observed number of prostate cancers was compared with the expected number during the same calendar period in an age matched male population to determine the standardized incidence ratio. The sensitivity of TRUS with multiple biopsies after 5 years of followup was calculated. Relative survival was estimated if there was an excess death rate due to undiagnosed prostate cancer.

RESULTS

We found 11 men diagnosed with prostate cancer. The expected number in the age standardized male population was 15, resulting in a standardized incidence ratio of 0.8 (95% CI 0.4 to 1.2). Five-year sensitivity of the extended protocol of TRUS guided biopsies was 95.2% (95% CI 93.5 to 96.4) and relative survival was more than 100%, indicating a selection of men deemed candidates for curative treatment.

CONCLUSIONS

Men with clinical suspicion of prostate cancer who are examined by an extended protocol of TRUS guided biopsies negative for cancer do not have an increased incidence of prostate cancer within 6 years compared with an age matched male population. Five-year sensitivity of this protocol was high.

Confidence intervals for the mean of a variable taking the values 0,1 and 2

The problem of setting a confidence interval for the mean of a variable on (0, 1,2) arises in three contexts: paired organ procedure rates; estimation of gene frequency, and three-point Likert scales. An effective approach to its estimation may be based on a good interval for a paired difference of proportions. Four good methods due to Newcombe and Tango are shown to have much better performance than more naive methods over regions of the parameter space corresponding to the above applications.

Transthoracic needle biopsy in the diagnosis of solitary pulmonary nodules: a survey of canadian physicians

OBJECTIVE

To describe Canadian physicians' opinions relative to the choice of diagnostic procedures in patients presenting with a solitary pulmonary nodule and to identify the attributes that may influence their decision.

METHODS

We conducted a mailed survey among Canadian physicians including pulmonologists, thoracic surgeons, radiologists, and internists. Five hypothetical clinical scenarios designed to illustrate a wide spectrum of clinical situations (including nodules associated to very low, indeterminate, and high probabilities of malignancy in patients medically fit or unfit to undergo surgical resection) were submitted to each physician who had to choose among options of diagnostic procedures and to estimate the pretest probability of malignancy.

RESULTS

The survey response rate was 47%. Overall, the physicians tended to overestimate the probability of malignancy. Twenty-eight percent of the respondents would have ordered a transthoracic needle biopsy in a medically fit patient presenting with a very low probability (< 2%) of malignancy, whereas 53% would have done so in a medically fit patient presenting with a very high probability (75%) of malignancy. In a regression analysis, the significant predictors of the use of transthoracic needle biopsy were (1) the pretest probability of cancer, (2) the patient's operability, (3) specialty (pulmonologists and thoracic surgeons being less likely to order a transthoracic needle biopsy than radiologists), and (4) the respondent's gender.

CONCLUSIONS

There are widespread variations in clinical opinions among Canadian physicians regarding the use of transthoracic needle biopsy in the investigation of solitary nodules. Hypothetical transthoracic needle biopsy was often preferred when the result was unlikely to affect patient management.

[Liver biopsy in Slovakia]

INTRODUCTION

Liver biopsy is the most specific diagnostic modality in hepatology, but information about its application in Slovakia is rather obscure.

METHODS

The authors performed a correspondence study with the aim to find out how many biopsy examinations has been done in Slovakia in 2001, for which indications, what kind of techniques have been applied and which small or great complications were encountered.

RESULTS

It was established that in the year 2001, 400 biopsies for diffuse liver diseases were performed. There were 296 percutaneous biopsies, 82 laparoscopic biopsies and 22 trans-jugular biopsies forming the survey. Acute viral hepatitis was the most frequent indication, whereas non-alcohol steatohepatitis was a rare indication in spite of the high prevalence. The frequency of great complications was 0.00025%. No death associated with this procedure was reported.

CONCLUSION

Liver biopsy has been done in Slovakia in indications, ways and with the frequency of complications, which were comparable with data from literature.

Cytomorphology of lipomatous tumors of soft tissue

OBJECTIVE

To evaluate the cytomorphologic features of benign and malignant lipomatous tumors of soft tissue on fine needle aspirates (FNA) and determine if the variants of liposarcoma could be identified.

STUDY DESIGN

FNA of histologically documented benign (51 cases) and malignant (39 cases) lipomatous tumors were reviewed. Twenty-six of the 51 FNA from lipomas and 34 of the 39 FNA from malignant lipomatous tumors were satisfactory for evaluation.

RESULTS

FNA from 26 cases of lipomas were cellular, with lobulated, fibroadipose tissue. Thin and thick capillaries were seen in 92% and 65% of cases, though a chicken wire vascular pattern was seen in only 4 cases (15%). A cytodiagnosis of liposarcoma could be made in 23 cases (88%), and these could be further subtyped into well-differentiated (4 cases), myxoid (8), pleomorphic (4), round cell (3) and liposarcoma, ?type (4). Only 50% of the well-differentiated liposarcomas, 3 of the 10 pleomorphic liposarcomas and 8 of the 17 myxoid liposarcomas were diagnosed as such on FNA. Cytologic diagnosis of the remaining 9 cases of myxoid liposarcoma were pleomorphic liposarcoma (1); liposarcoma, ?type (3); malignant mesenchymal tumor (1); suspicious for malignancy (2); and benign (2). There were no false positives, but there were 3 false negative cases (1 well-differentiated and 2 myxoid liposarcoma).

CONCLUSION

Lipomas can be diagnosed readily. Arborizing vessels can be seen in lipomas and should be interpreted with caution. Subclassification of liposarcomas on FNA is possible but not very reliable. Myxoid liposarcomas pose a problem, and aspirates from them can mimic a wide range of morphologic subtypes. The role of FNA in identification of variants of liposarcoma is limited.

Diagnostic value of needle aspiration cytology in the assessment of palpable axillary lymph nodes. A study of 336 cases

OBJECTIVE

To evaluate the diagnostic value of needle aspiration cytology (NAC) in the assessment of palpable axillary lymph nodes and determine whether ancillary procedures can be useful in enhancing the diagnosis.

STUDY DESIGN

The material was analyzed in 336 cases with enlarged axillary lymph nodes in which NAC were performed by the conventional method. In all cases cytologic examination was done on site after staining the smears with the Papanicolaou method. In addition, air-dried smears, fixed smears, filter preparations from needle washings and cell blocks were studied. The NAC diagnosis was supported by examining cell blocks, which showed the reliability of histologic architecture; further support was obtained with tissue biopsy and/or comparison with the primary tumor in some of the cases.

RESULTS

Twelve cases were diagnosed as inflammatory lesions, and 64 were unsatisfactory due to scanty/acellular samples (despite 2-3 repeat samplings). However, in 6 of these, malignant tumors were later found on a biopsy done due to persistent and continued enlargement of an axillary lymph node or nodes. One hundred twenty-two cases were regarded as negative (normal cellular elements, n = 52; reactive elements, n = 70), and 4 cases were suspicious for malignancy. In 124 cases a variety of metastatic tumors were diagnosed (breast, n = 63; melanoma, n = 22; others, n = 39), and in 10 cases a diagnosis of lymphoma was made.

CONCLUSION

NAC of palpable axillary lymph nodes as a first-line of investigation is a cost-effective procedure and is not only useful in the diagnosis of various lesions but can also help in deciding on management. Also, histologic architecture from cell blocks can be correlated with cytology, and such material can be used for histochemical and immunomarker studies.

Fine-needle aspiration cytology: its origin, development, and present status with special reference to a developing country, India

Fine-needle aspiration cytology (FNAC) was performed on a large scale at Memorial Hospital, New York, during the 1930s, but during the ensuing years, it did not gain much encouragement in United States. The technique had a resurgence in Scandinavia during the 1950s and 1960s, where it flourished before spreading to other parts of the world. It had also a revival in the United States, which contributed enormously to this tool in each and every aspect. The status of FNA during 1966-2002 was assessed through review of MEDLINE search data on FNA and its correlation with World Bank website data on classification of countries. A total of 849 journals published 5,609 articles on FNA over a period of 37 years. Both the number of publishing journals and the number of published articles on FNA were low during the 1960s (3.5 +/- 0.58 and 4.0 +/- 0.82, respectively) and 1970s (20.3 +/- 14.72 and 25.0 +/- 20.54, respectively), but their number increased sharply from the 1980s onward (78.2 +/- 25.65 and 147.2 +/- 66.89, respectively, during the 1980s, 126.2 +/- 11.94 and 301.4 +/- 35.99, respectively, during the 1990s, and 113.3 +/- 36.46 and 287.3 +/- 85.93, respectively, during the 2000s). The difference between the decades of 1960s-2000s, with respect to the number of publishing journals and published articles, was highly significant (P < 0.0001). Only 90 (10.6%) of the journals were from the arena of pathology and its branches. The remaining journals belonged to various other disciplines of medicine; a small fraction were even from the veterinary sciences. Ten journals, including three in the field of cytopathology, published 2,448 (43.6%) of the total articles on FNA. During 1987-2002, 46 (29.7%) of the 155 developing nations published articles on FNA, whereas 28 (52.8%) of the developed (high-income economies) countries did so, the difference being highly significant (P = 0.0044). The total number of publications from high-income economies was 3,124 (195.3 per year), as opposed to 772 (48.3 per year) from the developing world. The number of articles published from the developing nations (16.8 +/- 52.21) was significantly lower as compared with that from the high-income economies (111.6 +/- 242.03) (P = 0.005). Except for infectious diseases, the high-income economies had a definite edge over the developing nations in the absolute number of publications from each and every site/organ. However, when the frequency of publications on various organs/sites was compared between the two groups, it was found that the number of articles from high-income economies was significantly higher with respect to breast diseases (P < 0.001) and pancreatic lesions (P = 0.0158), whereas the developing nations published more frequently on small round cell tumors (excluding exclusive reports on lymphoma) and infectious diseases (P < 0.001). In India, FNAC was first introduced during the early 1970s and spread to different parts through formal teaching under the postgraduate curriculum in pathology and by conducting workshops and continuing medical education program for pathologists, surgeons/physicians, and radiologists. FNAC is now practiced in all medical colleges, in big public sector hospitals, and even in private clinics and laboratories. The number of centers practicing FNAC increased sharply during 1980s, as evident from the response of 69 laboratories in various parts of India to a questionnaire. As of 1998, 55.9% of the laboratories performed >/=1,000 cases of FNA per year. In 46% of the centers, pathologists alone performed the FNAC, whereas in 51%, they performed it in collaboration with radiologists and surgeons. Disposable syringes and needles were used in all the centers, but syringe holders were used in only in 61% of centers. In 86% of laboratories, two or more routine stains were used, and one or more ancillary techniques on fine-needle aspirates were adopted in 72.5% centers. Of the 772 publications from the developing world during 1987-2002, India alone contributed to 374 (48.4%). During 1975-2002, 154 articles on FNA were published needles were used in all the centers, but syringe holders were used in only in 61% of centers. In 86% of laboratories, two or more routine stains were used, and one or more ancillary techniques on fine-needle aspirates were adopted in 72.5% centers. Of the 772 publications from the developing world during 1987-2002, India alone contributed to 374 (48.4%). During 1975-2002, 154 articles on FNA were published in 15 indexed Indian journals.

Diagnostic value of open and needle biopsies in tumors of the sacrum

STUDY DESIGN

A retrospective study with statistical analysis of 25 percutaneous needle biopsies and 54 open biopsies performed on 60 patients with tumors located in the sacrococcygeal region.

OBJECTIVES

To analyze the diagnostic value of open and needle biopsies in tumors of the sacrum as well as to determine factors leading to a false or equivocal result.

SUMMARY OF BACKGROUND DATA

Although percutaneous needle biopsies of the spine are valuable for thoracolumbar levels, the benefit in the sacrococcygeal region, specifically, has not previously been shown. This region is unique because of anatomic and oncologic factors.

METHODS

Medical charts, imaging studies, and operative and pathologic records of patients with tumors diagnosed between 1965 and 1996 in the sacrococcygeal region reviewed were analyzed. Accuracy and effective accuracy of each procedure were then calculated.

RESULTS

There were 54 primary lesions (17 benign, 37 malignant) and 6 metastatic tumors. The accuracy and effective accuracy of open biopsies was 87% and 81% but in percutaneous needle biopsies was only 44% and 12%, respectively. An unclear diagnosis resulted in the need for another biopsy in 12 of 21 primary percutaneous needle biopsies but only in 2 of 39 open biopsies (P < 0.0001, chi2). The average number of biopsies required to obtain a definitive diagnosis was significantly less if an open biopsy were performed first instead of a percutaneous needle biopsy, 1.1 versus 1.8, respectively (P = 0.0004, two-sample t test). There was a significant delay in treatment if the initial biopsy was a percutaneous needle biopsy compared with an open biopsy, mean 46 versus 4 days, respectively (P = 0.004, two-sample t test).

CONCLUSION

We conclude that for sacral tumors, open biopsies have a higher effective accuracy, whereas needle biopsies are associated with a longer delay in treatment.

Reduction in the number of sentinel lymph node procedures by preoperative ultrasonography of the axilla in breast cancer

Currently, breast cancer patients without clinically suspicious lymph nodes are candidates for sentinel lymph node procedures (SLNPs). The aims of this study were to investigate whether preoperative axillary ultrasonography and fine-needle aspiration cytology (FNA) can reduce the number of the more time-consuming SLNPs, and to identify a subset of quantitative nodal features to predict metastatic involvement. 268 axillae were ultrasonographically examined. FNA was performed on suspicious nodes (smallest diameter > or =5 mm or atypical cortex appearance). SLNP was omitted if a tumour-positive node was found on FNA. Length, width, maximum cortex thickness and appearance of cortex and hilus were ultrasonographically established. In 93 axillae (35%), at least one node was detected with ultrasound. FNA was performed once per axilla on 66 nodes; 37 (56%) contained tumour cells. 31% of all tumour-positive axillae (macro-+micrometastases) was found by ultrasound and FNA (37/121). 41% of all axillae containing macrometastases was found by ultrasound and FNA (36/87). SLNPs were reduced by 14% (37/268). Maximum cortex thickness is the main feature to predict metastatic involvement (area under Receiver Operating Characteristic (ROC) curve (A(Z))=0.87).

Evaluation of transition zone and lateral sextant biopsies for prostate cancer detection after initial sextant biopsy

OBJECTIVES

To assess the value of transition zone and lateral sextant biopsies for the detection of prostate cancer after a previous sextant biopsy was negative.

METHODS

A total of 74 prostates after radical prostatectomy were used to perform biopsies ex vivo. First, a sextant biopsy was taken, then two different rebiopsy techniques were performed. Rebiopsy technique A consisted of a laterally placed sextant biopsy and two cores per side of the transition zones only. Rebiopsy technique B included a standard sextant biopsy and two cores per side from the lateral areas of the prostate. The biopsies were taken using ultrasound guidance to sample the areas of interest precisely.

RESULTS

The initial sextant biopsy found 39 prostate cancers. Rebiopsy technique A found 12 cancers (34%). In this group, a laterally placed sextant biopsy found 12 cancers; transition zone biopsies revealed cancer in 5 cases, but no additional tumor was found. Rebiopsy technique B detected 23 prostate cancers (66%). Fourteen tumors were found after a second standard sextant biopsy, and nine additional tumors were found in the lateral areas.

CONCLUSIONS

Sextant biopsy has a low sensitivity of only 53%. A biopsy including the transition zones is not the ideal technique for detecting the remaining tumors. Therefore, transition zone biopsies should be reserved for patients with multiple previous negative biopsies of the peripheral zone. A subsequent sextant biopsy with additional cores from the lateral areas of the prostate is favorable if rebiopsy is necessary after a negative sextant biopsy.

Comparison of percentage of total prostate needle biopsy tissue with cancer to percentage of cores with cancer for predicting PSA recurrence after radical prostatectomy: results from the SEARCH database

OBJECTIVES

Tumor volume in the prostate needle biopsy is an important prognosticator for patients with prostate cancer. However, the best method to measure tumor volume in the prostate needle biopsy is unknown. We compared the total percentage of biopsy tissue with cancer to the percentage of cores positive for their ability to predict adverse pathologic findings and biochemical failure after radical prostatectomy (RP).

METHODS

A retrospective survey of 355 patients from the Shared Equal Access Regional Cancer Hospital database treated with RP between 1990 and 2002 was undertaken. Multivariate analysis was used to compare the percentage of cores and percentage of tissue with cancer to the standard clinical variables of age, prostate-specific antigen (PSA) level, biopsy Gleason score, and clinical stage for their ability to predict positive surgical margins, non-organ-confined disease, seminal vesicle invasion, and time to PSA recurrence after RP.

RESULTS

On multivariate analysis, the percentage of tissue with cancer significantly predicted non-organ-confined disease and seminal vesicle invasion, but the percentage of cores did not significantly predict any of the pathologic features examined. In separate multivariate analysis, only the percentage of tissue with cancer, but not the percentage of cores with cancer, significantly predicted PSA failure. Moreover, when compared in the same multivariate analysis, only the percentage of tissue with cancer (hazard ratio 8.25, 95% confidence interval 3.06 to 22.22, P <0.001) was a significant predictor. The area under the receiver operating curves for predicting PSA failure was significantly greater for the percentage of tissue with cancer (0.697) than for the percentage of cores (0.644, P = 0.022). Cutpoints for the percentage of tissue with cancer (less than 20%, 20% to 40%, and greater than 40%) and the percentage of cores (less than 34%, 34% to 50%, greater than 50%) both provided significant preoperative risk stratification for biochemical failure, although the percentage of tissue with cancer cutpoints provided better risk stratification (higher hazard ratios and lower P value). Cutpoints for the percentage of tissue with cancer but not the percentage of cores positive further stratified patients who were at low (P = 0.041), intermediate (P = 0.002), and high (P = 0.023) risk on the basis of the PSA level and biopsy Gleason score.

CONCLUSIONS

The percentage of tissue with cancer was better than the percentage of cores at predicting advanced pathologic features and PSA recurrence after RP. Unlike the percentage of cores, the percentage of tissue with cancer cutpoints further stratified low, intermediate, and high-risk patients on the basis of PSA level and biopsy Gleason score. Although the percentage of tissue with cancer is a slightly more cumbersome measurement than the percentage of positive cores, it provided statistically and clinically superior preoperative risk stratification for biochemical failure after RP.

Using the percentage of biopsy cores positive for cancer, pretreatment PSA, and highest biopsy Gleason sum to predict pathologic stage after radical prostatectomy: the Center for Prostate Disease Research nomograms

OBJECTIVES

To develop probability nomograms to predict pathologic outcome at the time of radical prostatectomy (RP) on the basis of established prognostic factors and prostate biopsy quantitative histology.

METHODS

Using information from the database of the Center for Prostate Disease Research (CPDR), univariate and multivariate analyses were performed on 1510 men who had undergone transrectal ultrasound and biopsy for diagnosis and had radical prostatectomy as primary therapy, with variables of age, race, clinical stage, pretreatment prostate-specific antigen (PSA), biopsy Gleason sum, and percentage of biopsy cores positive for cancer (total number of cores positive for cancer divided by the total number of cores obtained). The percentages of biopsy cores positive were grouped as less than 30%, 30% to 59%, and greater than or equal to 60%. The three most significant variables were used to develop probability nomograms for pathologic stage.

RESULTS

PSA, biopsy Gleason sum, and percentage of cores positive were the three most significant independent predictors of pathologic stage. The assigned percentage of biopsy core-positive subgroups along with pretreatment PSA and highest Gleason sum were used to develop probability nomograms for pathologic stage.

CONCLUSIONS

Pretreatment PSA, highest biopsy Gleason sum, and the percentage of cores positive for cancer are the most significant predictors for pathologic stage after radical prostatectomy. On the basis of these findings, CPDR probability nomograms were developed to predict pathologic outcome at the time of RP.

Protocol core needle biopsy and histologic Chronic Allograft Damage Index (CADI) as surrogate end point for long-term graft survival in multicenter studies

This study is an investigation of whether a protocol biopsy may be used as surrogate to late graft survival in multicenter renal transplantation trials. During two mycophenolate mofetil trials, 621 representative protocol biopsies were obtained at baseline, 1 yr, and 3 yr. The samples were coded and evaluated blindly by two pathologists, and Chronic Allograft Damage Index (CADI) score was constructed. At 1 yr, only 20% of patients had elevated (>l.5 mg/100 ml) serum creatinine, whereas 60% of the biopsies demonstrated an elevated (>2.0) CADI score. The mean CADI score at baseline, 1.3 +/- 1.1, increased to 3.3 +/- 1.8 at 1 yr and to 4.1 +/- 2.2 at 3 yr. The patients at 1 yr were divided into three groups, those with CADI <2, between 2 and 3.9, and >4.0, the first two groups having normal (1.4 +/- 0.3 and 1.5 +/- 0.6 mg/dl) and the third group pathologic (1.9 +/- 0.8 mg/dl) serum creatinine. At 3 yr, there were no lost grafts in the low CADI group, six lost grafts (4.6%) in the in the elevated CADI group, and 17 lost grafts (16.7%) in the high CADI group (P < 0.001). One-year histologic CADI score predicts graft survival even when the graft function is still normal. This observation makes it possible to use CADI as a surrogate end point in prevention trials and to identify the patients at risk for intervention trials.

Lesions missed on prostate biopsies in cases sent in for consultation

BACKGROUND

There are no reports on how often lesions are missed on prostate needle biopsies.

METHODS

Over a 10-month period, 8/99 to 5/00, 3,251 prostate biopsy cases were seen in consultation.

RESULTS

We identified 87 (2.7%) patients with missed lesions (n = 9 academic hospitals; n = 44 community hospitals; n = 34 commercial labs). Overall, 119 lesions were missed in 87 patients. Missed lesions were as follows: small atypical glands suspicious for cancer (41 lesions in 35 patients), prostatic adenocarcinoma (39 cancers in 32 patients), high grade prostatic intraepithelial neoplasia (HGPIN) (34 lesions in 30 patients), and HGPIN with adjacent small atypical glands (five lesions in five patients)--some men with more than one type of missed lesion. Detection of the missed lesions would have resulted in either: a definite change in care in 15 of 3,251 (0.5%) patients or a possible change in care (bilateral cancer vs. unilateral cancer; HGPIN vs. atypical) in 17 (0.5%) patients. In 21 (24%) of the cases, the slides were seen by at least two pathologists prior to consultation at our hospital.

CONCLUSIONS

Although the number of prostate biopsies with missed lesions in a consult-based population of prostate biopsies appears relatively high (2.7%), the detection of the missed lesions would have only effected a definite change in care in 0.5% of all patients or a possible change in care in another 0.5% of patients. Our data underestimates missed lesions, as the entire specimen was not submitted for review in 41% of cases. Although our incidence of missed lesions gives some indication as to the magnitude of the problem, it cannot be equated with the risk of missing lesions in unselected cases.

Combining fine-needle aspiration and core biopsy under CT fluoroscopy guidance: a better way to treat patients with lung nodules?

OBJECTIVE

The goal of our study was to evaluate the efficacy of the combined use of fine-needle aspiration and tissue core biopsy under real-time CT fluoroscopy guidance.

SUBJECTS AND METHODS

One hundred thirty-eight percutaneous needle lung biopsy samples were obtained by two methods. The samples obtained by tissue fine-needle aspiration underwent cytologic evaluation, and those obtained by core biopsy using an automated cutting needle underwent histologic evaluation. The final diagnosis was confirmed by independent surgical pathologic findings, independent culture results, or clinical follow-up.

RESULTS

Rates of adequate specimens obtained and of precise diagnosis by combined use of fine-needle aspiration and core biopsy were 97.1% (134/138) and 94.2% (130/138) evaluated lung lesions, respectively, whereas those rates were 84.8% (117/138) and 79.7% (110/138) by fine-needle aspiration alone and 91.3% (126/138) and 89.1% (123/138) by core biopsy alone, respectively. Precise diagnosis was achieved by the combined use of the techniques in 30 (93.8%) of 32 lesions ranging from 3 to 10 mm in diameter, 42 (93.3%) of 45 lesions ranging from 11 to 20 mm, 43 (93.5%) of 46 lesions ranging from 21 to 30 mm, and 100% of 15 lesions ranging from 31 to 100 mm. In 89 of 90 lesions shown to be malignant by CT-guided lung biopsy and 30 of 44 shown to be benign, specific cell types could be proven from specimens obtained by the combined use of the two different types of needle biopsy.

CONCLUSION

The combined use of fine-needle aspiration and core biopsy improves the diagnostic ability of CT fluoroscopy-guided lung biopsy, even in small lesions.

Utilization of fine-needle aspiration in patients undergoing thyroidectomy at two academic centers across the Atlantic

Although fine-needle aspiration (FNA) has been accepted as a first-line test in patients with thyroid masses, the utilization of FNA varies even among experienced surgeons. To determine its utility we compared FNA results, pathology, and clinical results in patients who underwent thyroidectomy in two major endocrine centers on both sides of the Atlantic: one in the United States (US) and another in the United Kingdom (UK). Between January 1997 and March 1998 a total of 84 patients underwent thyroid surgery at the UK center, and 143 underwent thyroidectomy at the US center. The most common indication for thyroidectomy at the UK center was compressive goiter (CG), whereas follicular neoplasm (FN) was the most common indication at the US center. Bilateral thyroid resections, frozen section utilization, and thyroid cancer surgery were more common at the US center. Thyroidectomy for symptomatic multinodular goiter and Graves' disease was more prevalent at the UK center. Thyroid gland weights were also significantly greater in the UK, indicating a higher incidence of endemic goiter. FNA was more commonly employed in the US center (84% vs. 52%; p < 0.001). Despite the differing utilization of FNA at these major endocrine centers, only one thyroid cancer at each institution was not detected preoperatively (both patients had a benign FNA result). Therefore there were no clinically significant thyroid cancers found in patients who did not undergo preoperative FNA. In conclusion, FNA appears to be differentially utilized depending on the incidence of endemic goiter, Graves' disease, and thyroid cancer. In this series no clinically significant thyroid cancers were found in patients who did not undergo preoperative FNA. Therefore in the hands of experienced thyroid surgeons, FNA can be utilized selectively based on the clinical presentation.

Repeated thoracentesis: an important risk factor for eosinophilic pleural effusion?

BACKGROUND

Eosinophilic pleural effusion (EPE) is a relatively rare clinical condition. Repeated thoracenteses (RTs) are normally considered a frequent cause of EPE. Yet, to our knowledge, there is no firm evidence (apart from anecdotal case reports) supporting such a statement.

OBJECTIVE

To investigate potential relationships between the number, type (with or without pleural biopsy) and time elapsed between RTs and the number of eosinophils present in pleural fluid samples.

METHODS

We reviewed retrospectively 273 pleural fluid samples belonging to 120 patients (79 males, 41 females), attended in our institution from 1992 to 2000, whose clinical management had required RTs. Apart from the anthropometric and clinical data of each patient, we included the following variables in the analysis: number of thoracenteses performed in each individual, number of pleural biopsies carried out at each thoracentesis and time between consecutive thoracenteses. We also recorded the total (and differential) leukocyte count, red blood cell count, as well as the main biochemical, microbiological and histological data of both the pleural fluid and peripheral blood samples.

RESULTS

We did not observe any significant change in the percentage of eosinophils in relation to the number of thoracenteses performed per patient. This lack of relationship was also observed in the subgroup of patients who required one (or more) pleural biopsies (n = 111) (regardless of the number of biopsies). Our results suggest that RTs are not an important risk factor for the development of EPE, regardless of the time elapsed between two thoracenteses.

CONCLUSION

We believe, therefore, that multiple punctures should not longer be considered a prevalent cause of pleural eosinophilia.

Can total and transition zone volume of the prostate determine whether to perform a repeat biopsy?

OBJECTIVES

To compare the ability of total prostate (TP) and transition zone (TZ) volume to predict the outcome of a repeat prostate biopsy in patients with serum prostate-specific antigen (PSA) levels of 4 to 10 ng/mL.

METHODS

A total of 1137 patients were included and underwent transrectal ultrasound-guided needle sextant and two transition zone biopsies of the prostate. All patients with a prior negative biopsy (benign prostatic tissue) underwent a repeat biopsy after 6 weeks. The TP and TZ volumes of the prostate were measured by transrectal ultrasonography.

RESULTS

Of the 1137 patients, prostate cancer was diagnosed in 364 (32%), in 276 (24.2%) after the first biopsy and in 88 (7.7%) after the repeated biopsy. The TP and TZ volumes were larger in the patients with prostate cancer detected on the repeated biopsy (P <0.0001). Using a cutoff for TP volume of less than 20 cm3 and greater than 80 cm3 and for TZ volume of less than 9 cm3 and greater than 41 cm3 would have spared 7.1% and 10% of repeated biopsies, respectively.

CONCLUSIONS

The probability for a positive repeat prostate biopsy increases in a logarithmic function for larger prostates, as well as for larger TP and, especially, for larger TZ volumes. The probability of finding prostate cancer on a repeat biopsy in prostates with small (less than 20 cm3) and large (greater than 79 cm3) TP, as well as in small (less than 9.3 cm3) and large (greater than 41 cm3) TZ volumes, was very low. Therefore, a repeat prostate biopsy within 6 weeks is unnecessary. These patients should be followed up by serial PSA determination.