[Ultrasonography-guided transperineal prostatic biopsy: optimization of sampling protocol after 1,352 biopsies]

We report our experience-based approach in transperineal ultrasound guided biopsy to detect early prostate cancer. We selected patients on the basis of clinical characteristics. We tried to determine correct number and sites of biopsy to reduce patient discomfort and complications without loosing sensibility. Routine TZ biopsy increases detection rate of prostate cancer in T1 patients. Lateral peripheral biopsy resulted in a loss of sensibility of 5% and thus we considered it useless. Literature reported gain of sensibility with lateral peripheral biopsy referred to transrectal technique. Needle angle of incidence is different and therefore the area biopsied differs. Thus, results are not comparable.

Parotid gland tumours in 255 consecutive patients: Mount Sinai Hospital's quality assurance review

Parotid neoplasms represent a diverse group of tumours found in the head and neck. Complications following parotidectomy, including Frey's syndrome, facial nerve paralysis, sialoceles, and parotid fistulae, have been well documented. A retrospective review of 255 patients treated surgically for parotid masses over an 8-year period at Mount Sinai Hospital in Toronto was reviewed as part of a quality assurance program. The sensitivity, specificity, and predictive values for fine-needle aspiration cytology were analyzed. The incidence of benign and malignant lesions is presented. The complications following parotidectomy are reviewed and in our series are consistent with the figures published in the literature.

[Can indexes based on PSA determine which patients should undergo repeated ultrasound-guided transrectal prostatic biopsy? Study on 546 patients who underwent repeated biopsy]

OBJECTIVES

Ultrasound guided prostate biopsy is the most effective test for prostate cancer diagnosis, but its sensitivity is not higher than 80% so that biopsy repetition must be considered in patients with persistent diagnostic doubts after a previous negative one. However, the majority will be negative as it happened in the first biopsy and the percentage of normal biopsies increases successively. Various indexes based on PSA are proposed to determine which patients have a higher risk of cancer detection by biopsy. We evaluate the efficacy of PSA density (PSAD), free/total PSA ratio (F/T PSA) and PSA velocity (PSAV) to select patients with high PSA and previous negative biopsy.

METHODS

546 patients who underwent more than one prostate biopsy were included in the study. 121 patients underwent 3 biopsies, 25 underwent 4 biopsies and 7 five biopsies, for a total of 1245 biopsies. Patients already diagnosed of prostate cancer who had received treatment, and postoperative urethrovesical anastomosis biopsies were excluded. Between 4 and 6 samples were obtained; transitional zone was included if previous biopsy was negative; sextant biopsy was repeated in high grade PIN, and 4 or 5 cores were taken from the affected side in cases with non conclusive glandular atypia. The relationship between PSAD, PSAV and F/T PSA and the diagnosis of cancer was evaluated, as well as its sensitivity, specificity, positive and negative predictive values.

RESULTS

21.2% patients presented cancer on 2nd biopsy and 26% overall. Mean age was 68.3 years (51-84). Patients with cancer and negative biopsy showed significant differences in F/T PSA and PSAD, but not in PSAV. Sensitivities for PSAD higher than 0.15 ng/ml/ml, F/T PSA lower than 0.18 and PSAV higher than 0.75 ng/ml/year were 0.89, 0.9 and 0.49 respectively and specificities were 0.28, 0.2 and 0.4 respectively. ROC curve areas were calculated for these indexes being 0.63 for F/T PSA, and 0.47 for PSAV.

CONCLUSIONS

Although their specificity is low, free to total PSA ratio and PSA density showed the highest sensitivity; PSAV is almost non valid to discriminate the result in the biopsy. Although we could slightly diminish the number of repeat biopsies loosing a few tumors, only the urologist can determine when biopsies should be repeated in patients with elevated PSA, taking into consideration all concurrent factors (Baseline status, age, risk-benefit ratio of new biopsies...).

An audit of the accuracy of fine needle aspiration using a liquid-based cytology system in the setting of a rapid access breast clinic

We have assessed the effectiveness and accuracy of reporting fine needle aspirates of the breast (FNAB) using a liquid-based cytology (LBC) system (the Cytospin) method) in the pressure situation of a rapid access clinic (RAC). We have reviewed every case from the RAC from June 1997 to February 2001 inclusive. There were 1322 cases, which accounted for 26% of the total FNAB received in our department over the period. There were 323 cancers and 999 benign cases in the group. The inadequate/nondiagnostic rate (C1) was 18%. The absolute sensitivity, including C1 cases, was 73% with the complete sensitivity being 90%. The groups of 'atypical, probably benign' (C3) and 'suspicious, probably malignant' (C4) accounted for a total of 6.2%. There were 28 false negative cases and 1 false positive case (a borderline phyllodes tumour). Comparing our results with the standards recommended by the NHSBSP has shown that the diagnosis of FNAB using this LBC method is feasible, accurate and reliable even in the pressure situation of a RAC.

Fine needle aspiration biopsy (FNAB) for retinoblastoma

PURPOSE

To determine the incidence of diagnostic fine needle aspiration biopsy (FNAB) in eyes with retinoblastoma (RB) as well as its indications and potential complications.

METHODS

A retrospective study by survey was designed and a questionnaire inquiring on FNAB use in RB diagnosis during the past 15 years was submitted to 12 high-volume ocular oncology clinics.

RESULTS

A total of 3,651 patients with RB have been diagnosed and treated in 12 clinics since 1985. During the same period, eight biopsies were obtained for diagnostic purposes and six of these proved to be RB by cytology; the other two showed inflammatory cells and benign retinal cells. The median age for the biopsied patients was 46 months; 6 of the biopsied children were older than 4 years of age. The average age at the time of biopsy was 46 months. Most of the cases were biopsied with clinical diagnosis of uveitis/endophthalmitis through the limbus and pars plana with 25- and 27-gauge needles. Five of six cases of RB had enucleation and one patient had cryotherapy and I-125 brachytherapy after FNAB. The average follow-up time for biopsy-proven RB cases was 10.8 years with no recurrent disease.

CONCLUSION

The results of this survey suggest that FNAB indication for RB diagnosis is rare; the majority of cases can be diagnosed and treated by ocular oncologists without invasive procedures.

Audit of transthoracic fine needle aspiration of the lung: cytological subclassification of bronchogenic carcinomas and diagnosis of tuberculosis

INTRODUCTION

Transthoracic fine-needle aspiration cytology (FNAC) is a useful tool for evaluating neoplastic and inflammatory lung nodules. In view of the relative paucity of published audit studies regionally, such a study was undertaken to assess the use of the technique in our centre.

METHODS

One hundred and fourteen FNACs were performed during 1997-1999. Immediate assessment for specimen adequacy was done. Diagnoses were correlated with clinical-pathological information and selective blind review performed.

RESULTS

Cytologically, 65.8% of cases were malignant, 1.8% were atypical, 25.4% were inflammatory/non-malignant and 7% were inadequate. Cytological-histological tumour diagnostic concordance was 94.4%. Diagnostic sensitivity for malignancy: 93.4%, specificity: 95.8%, accuracy: 94%. Eight inadequate/ benign cases (7%) proved to be malignant with clinical-pathological follow-up. Tuberculosis was confirmed (acid-fast bacilli detected) in six cases (5.3%) and suggested in a further 10 cases (8.8%). The cytological review showed 96% concordance with the original benign/malignant diagnoses. Pneumothorax rate was 18%.

CONCLUSION

FNAC is an accurate and safe method for the evaluation of lung nodules and it enables subclassification of bronchogenic carcinomas in the vast majority of cases. It is also useful for the diagnosis of tuberculous pulmonary nodules. Immediate assessment optimises specimen adequacy; inadequate/non-malignant smears in particular, need clinical correlation, close follow-up and re-biopsy, if necessary.

Prediction of outcome after radical prostatectomy in men with organ-confined Gleason score 8 to 10 adenocarcinoma

OBJECTIVES

Most adenocarcinomas of the prostate with a Gleason score greater than 8 at radical prostatectomy have extraprostatic extension and a high risk of progression. With prostate-specific antigen screening, we have seen some cases of earlier detected, organ-confined, high-grade adenocarcinoma. Few data are available as to the likelihood of cure in these cases.

METHODS

We reviewed 27 cases of pathologically organ-confined adenocarcinoma with a prostatectomy Gleason score of 8 to 10. To exclude cases with a significant proportion of Gleason pattern 3, we excluded cases of Gleason score 3+5=8 and Gleason score 5+3=8. All cases of Gleason score 8 at radical prostatectomy were Gleason score 4+4. The prognostic value of the clinical parameters (clinical stage, serum prostate-specific antigen level, age) and pathologic factors (biopsy Gleason score, radical prostatectomy Gleason score, prostatectomy tumor volume) were tested to predict postoperative progression.

RESULTS

The mean age at diagnosis was 59.7 years (range 46 to 69) with preoperative serum prostate-specific antigen levels ranging from 1.4 to 28 ng/mL (mean 7.8). All tumors were classified as pathologic Stage T2N0Mx. Fifteen patients (55.6%) had a Gleason score of 8, 11 patients (40.7%) had a Gleason score of 9, and 1 had a Gleason score of 10 (3.7%). Tumor volumes ranged from 0.02 to 1.44 cm(3) (mean 0.56). Follow-up information was available for all men. The mean follow-up for those without progression was 30.6 months (range 7 to 73) and for those with progression was 23.6 months (range 9 to 44). The 33-month actuarial risk of progression was 32%, with 10 men developing progression during the study. None of the preoperative or postoperative variables predicted progression.

CONCLUSIONS

Even when high-grade tumor is organ confined, it is associated with a relatively unfavorable short-term outcome that is not predictable on the basis of either preoperative clinicopathologic data or postoperative pathologic information obtained from the radical prostatectomy specimen.

Laparoscopic radical prostatectomy. preliminary pathologic evaluation

OBJECTIVES

Although there is increasing evidence of the interest in the laparoscopic approach for radical prostatectomy, carcinologic data, including surgical margin status, remain to be described.

METHODS

We analyzed the oncologic results of laparoscopic prostatectomies performed during 2000. The data were compared with retropubic prostatectomies performed between 1994 and 1997 by the same two senior urologists. After matching for preoperative prostate-specific antigen level, the final analysis included 139 patients in both groups, with similar data for age, biopsy Gleason score, and number of positive biopsies. All specimens were processed with the same method of pathologic evaluation. The results were compared using either the chi-square test or Student t test.

RESULTS

The mean prostate weight and rate of positive lymph nodes were similar in both groups. No statistical difference was observed in the distribution of either the radical prostatectomy Gleason score or the pathologic stage between the laparoscopic and retropubic groups. In contrast, the decrease in the rate of positive surgical margins was statistically significant in the laparoscopic approach compared with the retropubic approach (P <0.02), particularly in localized cancers (pT2). No difference was observed in either the length or the distribution of the margin location. The rate of positive apical margins in organ-confined disease was significantly decreased in the laparoscopic group.

CONCLUSIONS

These results suggest that laparoscopic prostatectomy performed by trained surgeons does not lead to an increased risk of positive margins compared with the retropubic approach.

A prospective review of the decline of excisional breast biopsy

BACKGROUND

Although excisional breast biopsy has long been considered the standard for breast cancer diagnosis, core biopsies are now used more frequently. Whether core biopsy can eventually replace excisional biopsy remains unknown. The purpose of this study was to evaluate the relationship between diagnostic excisional and core biopsies relative to surgical treatment procedures.

METHODS

We analyzed our data collected prospectively from 1995 through 2000, which included inpatient and outpatient surgical data, office visits, and radiology biopsy data including stereotactic, mammotome, and ultrasound core biopsies. The Cochran-Armitage trend test was used to assess the shift in diagnostic technique.

RESULTS

From 1995 through 2000 there were 2,631 core biopsies performed, 2,685 excisional biopsies, 2,881 surgical procedures for breast cancer, and 51,109 office visits. Although the percentage of core biopsies relative to excisional biopsies increased from 31% to 68% (P <0.001), the percentage of biopsies relative to the number of office visits remained stable at 10% to 11%. The percentage of breast cancer procedures relative to office visits also remained stable at 5% to 6%.

CONCLUSIONS

Our data indicate that core biopsies are being performed more often than excisional biopsies. Nevertheless, one in three biopsies done at our institution is excisional.

Percutaneous lung biopsies: a survey of UK practice based on 5444 biopsies

Percutaneous transthoracic lung biopsies are commonly performed for the investigation of lung masses. We describe current practice and complication rates in the UK. A postal questionnaire was sent to all centres in the British Thoracic Society directory. 157 replies (61% response rate) were received, providing data on 5444 biopsies. Mean number of biopsies performed per annum was 30.5 per centre; 8% of centres did not perform biopsies, 36% performed <25 biopsies per annum, 34% <50, 16% <100 and 6% >100. Consultant radiologists perform 91% of biopsies. Written consent was obtained at all centres. The operator obtained consent at 50% of centres. Written information for patients was provided at 35 (24%) centres. Biopsies are performed on a day case basis at 103 (71%) centres. Prior to biopsy the following were obtained routinely: CT scan (73% of centres), platelet count (73%), full clotting screen (70%), lung function (55%). Complications included pneumothorax (20.5% of biopsies), pneumothorax requiring chest drain (3.1%), haemoptysis (5.3%) and death (0.15%). The timing of post-procedure chest radiography was variable. Those centres that performed predominantly cutting needle biopsies had similar pneumothorax rates to centres performing mainly fine needle biopsies (18.9% vs 18.3%). There is great variation in practice throughout the UK. Most procedures are performed on a daycase basis. Small pneumothoraces are common but infrequently require treatment. National guidelines are needed to ensure consistency of standards.

PSA response to finasteride challenge in men with a serum PSA greater than 4 ng/ml and previous negative prostate biopsy: preliminary study

OBJECTIVES

To determine, in a prospective study, the prostate-specific antigen (PSA) response to finasteride challenge in men with a serum PSA greater than 4 ng/mL who had undergone previous biopsy. Patients with a serum PSA level greater than 4 ng/mL who have undergone repeated prostate biopsy with prostate cancer (CaP) that was not detected present a diagnostic dilemma. The magnitude of PSA reduction after administration of finasteride has been well documented. In addition, doubling of the PSA value after 1 year of finasteride has been touted to be a more useful paradigm for diagnosing CaP than PSA alone.

METHODS

Thirty-eight men with a baseline serum PSA level greater than 4 ng/mL and a normal digital rectal examination who had been previously biopsied a minimum of two times, with CaP not detected, were given 5 mg finasteride daily. The PSA level was measured at 6 and 12 months with repeat transrectal ultrasonography and biopsy (12 cores) performed at 1 year. Changes in prostate volume, serum PSA, PSA density, and the incidence of CaP at 1 year were assessed.

RESULTS

The mean age of the group was 60.5 years (+/-7.6). For the group, the average number of previous biopsies performed was 2.9 (range 2 to 6). The baseline PSA level for the entire group was 6.32 ng/mL (+/-3.2), and the baseline prostate volume was 37.3 cm3 (+/-12.4). At 1 year, the PSA level had decreased to 3.73 ng/mL (-41.0%), and the prostate volume had decreased to 30.4 cm3 (-18.5%). In the 11 men (29%) in whom CaP was detected, the serum PSA decreased from 7.3 to 5.2 ng/mL (-28.8%) and the prostate volume decreased from 37.3 to 32.3 cm3 (-13.4%). CaP was detected in 0 of 10 men with a serum PSA decrease of 50% or higher, in 6 (32%) of 19 men with a PSA decrease between 33% and 50%, and in 5 (56%) of 9 men who had a PSA decrease of less than 33%.

CONCLUSIONS

The data in this preliminary study suggest that the magnitude of change in serum PSA after 1 year of finasteride challenge may be useful in diagnosing CaP in patients with elevated PSA levels and prior negative prostate biopsy.

Robustness of free prostate specific antigen measurements to reduce unnecessary biopsies in the 2.6 to 4.0 ng./ml. range

PURPOSE

Prostate specific antigen (PSA) cutoffs lower than 4.0 ng./ml. are being evaluated more frequently but lower PSA cutoffs increase the number of prostatic biopsies. PSA exists in several forms free and complexed to proteins. Percent free PSA is lower in men with prostate cancer. Accordingly, free PSA and complexed PSA have been used to distinguish between cancer and benign disease in the diagnostic gray zone of 4 to 10 ng./ml. to eliminate unnecessary biopsies. There are limited data on the robustness of free PSA measurements in the 2.6 to 4.0 ng./ml. total PSA range.

MATERIALS AND METHODS

We evaluated percent free PSA measurements to discriminate between cancer and benign conditions in 965 consecutive volunteers in a prostate cancer screening study who underwent prostatic biopsy for a PSA of 2.6 to 4.0 ng./ml. and had benign digital rectal examination.

RESULTS

Overall 25% of men had cancer detected. A 25% free PSA cutoff detected 85% of cancers and avoided 19% of negative (cancer-free) biopsies, while a 30% free PSA cutoff detected 93% of cancers and avoided only 9% of negative biopsies. Of those men who underwent radical prostatectomy 132 (80%) had pathologically organ confined tumors. Only 5% of these tumors fulfilled the published pathological criteria for possibly clinically unimportant tumors.

CONCLUSIONS

Percent free PSA provides risk assessment but does not eliminate many unnecessary prostatic biopsies while maintaining a high sensitivity in the narrow total PSA range of 2.6 to 4.0 ng./ml.

Large-needle core biopsy in atypical intraductal epithelial hyperplasia including immunohistochemical expression of high molecular weight cytokeratin: analysis of results of a single institution

The diagnosis of atypical intraductal epithelial hyperplasia (AIDH) constitutes 6.3% of the breast core biopsies performed at our institution. Seventy-nine cases that were diagnosed as AIDH on core biopsy and went through excisional biopsy were included. Sixty-four biopsies were performed by an image-guided 11-gauge vacuum device, 11 under sonographic guidance using 14-gauge needles and 4 by a sonographically guided 11-gauge vacuum device. The histopathology of the core biopsies and the surgical excisions were reviewed. Immunohistochemistry was performed on the consecutive sections of core biopsy specimens using high molecular weight cytokeratin (HMW-CK) (DAKO-Cytokeratin, 34betaE12). At interpretation of the stain, intensity and percentage of positive cells were taken into account. The immunoprofiles of AIDH were categorized into four groups showing negative (i.e., no staining) or low-, moderate-, high-, and very high-intensity staining. Surgical excision of the 79 lesions revealed carcinoma in only 3 cases (4%)-two infiltrating carcinomas and one intraductal carcinoma-residual AIDH in 44 cases (56%), and epithelial hyperplasia or other benign lesions without atypia in 32 cases (40%). The HMW-CK stain was performed retrospectively on all of the core biopsies and 66 of them contained residual areas with AIDH for staining. Forty-nine (74%) were CK negative or stained with low intensity, but 17 cases (26%) had a moderate- to high-intensity stain. Our study showed a lower incidence of carcinoma on surgical excision following core biopsy for AIDH than other studies. The HMW-CK stain helped to characterize the nature of the intraductal proliferation and to confirm the presence of atypia, as has been previously reported, but frequently was inconclusive. The low incidence of carcinoma brings into question the need for surgical excision of all cases of AIDH diagnosed by core biopsy.

Effect on biopsy technique of the breast imaging reporting and data system (BI-RADS) for nonpalpable mammographic abnormalities

OBJECTIVE

To determine if the breast imaging reporting and data system (BI-RADS) defines a group of patients with mammographic abnormalities in whom stereotactic core needle biopsy (SCNB) is appropriate.

DESIGN

A blinded retrospective validation sample.

SETTING

A university-affiliated hospital.

PATIENTS

One hundred and nine consecutive patients who underwent fine-wire localization breast biopsy (FWLB) between Jan. 1, 1994, and June 1, 1999, with a known final pathological diagnosis.

INTERVENTION

Blinded mammographic review and classification using the BI-RADS; review of corresponding pathological findings from FWLBs.

OUTCOME MEASURES

Correlation of pathological findings with each BI-RADS category and analysis of the predictive value of clinical and radiologic features.

RESULTS

BI-RADS findings were as follows: 0 malignant lesions in 10 category 3 cases, 18 malignant lesions (3 in situ, 15 invasive) in 68 category 4 cases and 24 malignant lesions (8 in situ and 16 invasive) in 31 category 5 cases. There was 1 malignant lesion in 22 category 4 cases in women younger than 50 years.

CONCLUSIONS

SCNB should be applied to BI-RADS categories 3 and 4 (< 50 yr of age). FWLB should be reserved for category 4 (> 50 yr of age) and category 5 cases. This algorithm will reduce the morbidity and cost of breast biopsies in patients with nonpalpable mammographic abnormalities.

A survey of current liver biopsy practice patterns

GOALS

To survey clinicians regarding current liver biopsy practice patterns.

BACKGROUND

Although the hepatitis C epidemic has increased the proportion of hepatology in general gastroenterology practice, many clinicians express concern regarding the risks of percutaneous liver biopsy.

STUDY

A questionnaire about liver biopsy practices was sent to members of the Duke University Digestive Epidemiological Studies Consortium.

RESULTS

The response rate was 112 (71%) of 157. Thirty-three (29.5%) physicians reported that they do not perform liver biopsies. Reasons cited for not performing biopsies included concern about risks (72.7%), low reimbursement (66.7%), and logistical issues with space and recovery time (45.4%). Routine practice was biopsy without ultrasound in 53.2%, ultrasound marking by a radiologist or technician at the time of biopsy in 24.0%, previous ultrasound marking in 17.7%, and ultrasound marking by the gastroenterologist in 5.1%. For patients with hepatitis C, 76.8% of clinicians perform routine biopsies before treatment.

CONCLUSIONS

A significant proportion of clinicians do not perform liver biopsies; common reasons include the risks of the procedure and the low reimbursement. The use of ultrasound with liver biopsy has become more common. New approaches, especially in training programs, may be necessary to make clinicians more comfortable with this procedure.

Diagnostic accuracy of prostate needle biopsy

The introduction of prostate-specific antigen screening has resulted in stage migration and an increased incidence of localized prostate cancer. In this era of increasing nonpalpable disease, it has become necessary to systematically sample the entire prostate gland. Transrectal ultrasound-guided prostate biopsy procedures have evolved greatly over the past decade from the original sextant biopsy. Technological advances, better understanding of zonal anatomy of the prostate, whole mount sectioning of radical prostatectomy specimens, and computer modeling of localized prostate cancers have all led to extended biopsy core protocols directed at the lateral zones of the gland. These have increased the diagnostic accuracy of needle biopsy and have become a standard regimen. However, it remains controversial how to proceed with repeat biopsy in the face of an initial benign diagnosis, and optimal biopsy strategy remains undefined. It is hoped that quantitative analysis of prostate biopsy histology may eventually provide some prognostic information to guide the patient and urologist in preoperative planning.

[Analysis of liver biopsy experience in a regional hospital]

Hepatic biopsy is a safe procedure. Its findings contribute to precise diagnoses and in selecting or modifying the treatment of some patients with liver diseases.

AIM

To analyze indications, findings and complications of hepatic biopsy.

MATERIAL AND METHODS

Retrospective study of patients with hepatic disease in which a hepatic biopsy was obtained. Information pertaining to clinical characteristics, biopsy indications and its results were collected. All tissue samples were stained with hematoxylin-eosin, Masson and Perl. The analysis was performed by descriptive statistics, chi 2 test and the Fisher exact test.

RESULTS

There were 54.6% were women and 45.4% were men. In 361 patients the major diagnoses were: Hepatic cirrhosis 19.1%, hepatic metastases 16.3%, chronic hepatitis 11.6%, alcoholic hepatitis 11.1% and nonalcoholic steatohepatitis 9.7%. In 66.2% of the biopsies were preformed meanwhile patients were in the Hospital. The procedure was ultrasound-assisted in 76%. There were major complications in 1.4%.

CONCLUSION

The hepatic disease is more common in the woman and the pathologic results show that the etiology of liver diseases in our hospital are similar to reports of third level hospitals in Mexico, its major complications were fewer.

Should fine needle aspiration cytology in breast assessment be abandoned?

Fine needle aspiration cytology (FNAC) has been used extensively in the U.K. for the diagnosis of breast lesions over the past 15 years. More recently, large gauge needle biopsy has been used to address many of the problems which have been encountered with fine needle aspiration. This paper reviews the evolution of the use of these procedures and the advantages and disadvantages of each. In considering whether to abandon the use of fine needle aspiration cytology in breast assessment, each individual unit should make a decision based upon their own audited results. However, even if FNAC is retained, it is important to be able to complement cytological diagnosis with core biopsy as there are indisputable advantages, e.g. in the diagnosis of mammographically detected microcalcification. As always, a multi-disciplinary approach is ultimately essential for effective patient management.

[Intestinal and peritoneal tuberculosis]

BACKGROUND

Abdominal tuberculosis (tbc) is still a medical problem in developing countries. Since it imitates many abdominal diseases, diagnosis can be easily missed unless the disease is suspected.

METHODS

The aim of this study to evaluate the value of clinical, physical and laboratory findings and to discuss the diagnostic and therapeutic options in 121 patients with intestinal and peritoneal tbc. The diagnosis was made by histopathological examination of biopsy material and isolation of mycobacterium bacillus in cultures or smears of ascites fluid.

RESULTS

The diagnosis was confirmed with laparotomy in 102, laparoscopy in 4, colonoscopy in 6, and percutaneous aspiration in 9 patients. There were intestinal tbc in 67 (55.3%) patients and peritoneal tbc in 54 (44.6%). Intestinal involvement was commonly located at ileocecal area. Anti tuberculous chemotherapy was started and avoided from extensive resection in surgical treatment. There were a total of 87 complications in 52 patients (42.9%) at the postoperative period. Wound infection was the most frequent complication. Overall mortality rate was 13.2%. The mortality rate in emergency operation was 20.5% while 3.4% in elective conditions. There were no morbidity and mortality in patients whose diagnosis were made by conservative procedures.

CONCLUSIONS

Laparoscopic endoscopic and percutaneous aspiration procedures are useful for diagnosis in the selected cases of intestinal and peritoneal tbc. Laparotomy should be performed only when complication develops or diagnosis is uncertain. Extensive resection should be avoided in surgical treatment of intestinal tbc. Early diagnosis and treatment will decrease the complications that can be develop during the progress of the disease and consequently the mortality rates.

Does increased needle biopsy sampling of the prostate detect a higher number of potentially insignificant tumors?

PURPOSE

Several studies have documented that increased biopsy sampling, that is 6 versus 12 biopsy cores, can detect more prostate cancer. It is unknown whether increased sampling of the prostate will detect a higher number of potentially insignificant tumors.

MATERIALS AND METHODS

We searched the surgical pathology files at The Johns Hopkins Hospital for patients in whom prostate needle biopsy was performed by a single urologist between April 1993 and April 2000, and subsequently underwent radical prostatectomy. Patients who underwent radical prostatectomy and had 8 core biopsies or less between March 1994 and August 1999 were also studied. Clinically significant tumors were defined as those with volume greater than 0.5 cc, Gleason score 7 or greater or nonorgan confined disease.

RESULTS

A total of 297 patients with a mean age of 60 years (range 36 to 75) were evaluated. Group 1 consisted of 107 men with 8 core biopsies or less, including 51 with 6, and group 2 comprised 190 men with 9 cores or greater, including 145 with 12. The 2 groups were equal in regard to prostate specific antigen, age, digital rectal examination and transrectal ultrasound gland volume at biopsy. The only difference between the groups was a higher number of cores with cancer in group 2 (mean 2.8 versus 2.1, p = 0.0006). Of the patients who underwent radical prostatectomy 59.6% had Gleason score 6 or less, 26.3% 3+4, 6.7% 4+3 and 7.4% 8 to 9. There were 12.4% of patients with positive margins, 36.4% extraprostatic extension, and 5.4% seminal vesicle invasion and/or lymph node metastasis. Tumor volumes averaged 1.1 cc (range 0.01 to 10.7) and 60.9% of tumors were greater than 0.5 cc. Clinically significant tumors were seen in 77.4% of patients in group 1 and 74.6% in group 2. There was no significant difference in Gleason score, margin status, tumor volume, seminal vesicle invasion, or lymph node metastasis between groups 1 and 2, or in a subset analysis of men with 6 versus 12 core biopsies. However, patients in whom cancer was diagnosed with 9 core biopsies or greater were more likely to have organ confined disease (p = 0.02).

CONCLUSIONS

Although increased sampling of the prostate does not increase the detection of potentially insignificant tumors, it does appear to detect earlier stage cancer.

The utility of EUS and EUS-guided fine needle aspiration in detecting celiac lymph node metastasis in patients with esophageal cancer: a single-center experience

BACKGROUND

The aims of this study were to determine the utility of EUS and EUS-guided fine needle aspiration (EUS-FNA) in the detection and confirmation of celiac lymph node metastasis in patients with esophageal cancer and to define EUS features predictive of celiac lymph node metastasis in these patients.

METHODS

The records of 211 patients with esophageal cancer who underwent EUS staging were reviewed. The operating characteristics of EUS were determined in patients where either surgery, EUS-FNA of a celiac lymph node, or both were performed (n = 102). The association between selected variables and the presence of celiac lymph node metastasis was evaluated by univariate and multivariable analyses.

RESULTS

EUS in 48 patients provided a true-positive diagnosis of celiac lymph node involvement, a false-positive and false-negative result, respectively, in 6 and 14 patients, and a true-negative diagnosis in 34 patients. The sensitivity of EUS in detecting celiac lymph node was 77% (95% CI [67, 88]), specificity 85% (95% CI [74, 96]), negative predictive value 71% (95% CI [58, 84]), and the positive predictive value 89% (95% CI [81, 97]). EUS-FNA was performed in 94% (51/54) of patients with celiac lymph nodes. The accuracy of EUS-FNA in detecting malignant celiac lymph nodes was 98% (95% CI [90, 100]). Advanced T-stage, the need for dilation, detection of peritumoral lymph nodes, and black race were associated with celiac lymph node involvement. In multivariable analysis, advanced T-stage was the strongest predictor of celiac lymph node involvement.

CONCLUSION

EUS and EUS-FNA are highly accurate in detecting and confirming celiac lymph nodes metastasis. Depth of tumor invasion as assessed by EUS is a strong predictor of celiac lymph node metastasis in patients with esophageal cancer.