The Diagnosis of Urinary Tract Infections Using a Novel At-home Testing Protocol to Enhance Telemedicine: A Retrospective Analysis

OBJECTIVE

To retrospectively analyze a novel courier-based home urine collection strategy for patients with symptoms of urinary tract infections (UTIs). This model was developed to provide patient care using telehealth during the coronavirus 2019 pandemic.

METHODS

We analyzed data from 2206 patients with symptomatic UTIs to investigate the efficacy of a home urine collection protocol. The primary outcome was the impact of home versus office collection.

RESULTS

We analyzed the results of 1112 patient samples collected in-office and 1084 patient samples collected at home. There was no difference in the rate of bacterial identification between females in the office and home collection groups. However, males in the office collection group had a higher rate of bacterial identification (p = .002). The turnaround time was significantly faster in the home collection group than the office collection group (4.08 hours shorter, p < 0.0014). Antibiotic use prior to sample collection was significantly higher in the home collection group for both males (p = .0004) and females (p = .004). Changes in antibiotics were significantly higher in the home collection group than in the office collection group for both males (p = .0009) and females (p = .0006).

CONCLUSION

Our home collection protocol is a viable method to provide prompt and reliable outpatient care to urology patients suffering from UTIs. Furthermore, this approach resulted in adequate management and quicker turnaround times. Our findings demonstrate the clinical viability of a decentralized healthcare model to treat UTIs.

Correlation of the rate of metastasis-free survival with the presence of pathogenic germline genetic mutations in patients with prostate cancer at a community practice

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Background: Loeb et al. recently highlighted that academic physicians were statistically more likely to recommend genetic testing to prostate cancer patients per NCCN guidelines compared to physicians at community practices. Several articles have outlined the rate of pathogenic mutations and metastasis free survival (MFS) for prostate cancer patients treated at academic institutions. However, there is a relative paucity of equivalent data regarding patients treated at community urology clinics. We felt it was important to retrospectively review data from our large community based uro-oncology practice and present our findings in an effort to clarify this topic. Methods: We collected data on 562 prostate cancer patients treated at our multidisciplinary uro-oncology clinic between 2016 and 2018. We found 363 patients that satisfied the inclusion criteria of having germline genetic mutation testing and at least 1 year of follow-up. Patients were stratified into three categories based on the results of their germline genetic test: negative for germline mutations, positive for germline pathogenic mutations, or positive for VUS (variant of uncertain significance) mutations. Analysis of variances (ANOVA) was conducted to assess for any differences in age, Gleason score, metastasis rate, and MFS across the groups. A significance level of.05 was used. Results: All patients were treated according to guideline recommendations as was standard for the practice. There was no statistically significant difference in average age or Gleason score between the groups. There was also no statistically significant difference between the MFS across the three groups. Although the metastasis rate and MFS in the group without any mutations (9.8%, 18.3 months) was clinically significant compared to the groups with pathogenic mutations (7.5%, 16.5 months) and VUS mutations (7%, 16.6 months), the differences were not statistically significant (p=.754 and.127 respectively). Conclusions: In our community based uro-oncology practice, we found no statistically significant difference in MFS between patients with pathogenic germline mutations, patients without germline mutations, and patients with VUS mutations at 1 year of follow-up. This does not exclude the possibility of an impact of germline mutations on MFS as the data matures to reach 5 or more years of follow-up.[Table: see text]

The positive impact of implementing an onsite guideline-based genetic testing procedure for prostate cancer in a multidisciplinary uro-oncology clinic

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Background: Prior to the guidelines set forth by the 2017 Philadelphia consensus conference, genetic testing for prostate cancer was conducted based on personal and family history of malignancies pursuant to NCCN recommendations. The 2017 guidelines expanded testing criteria to included age at diagnosis, metastatic disease, and tumor sequencing. In spite of these advancements, limited literature is available regarding successful implementation of a streamlined system for genetic testing in prostate cancer. This paper explores the benefits of implementing an on-site guideline-based genetic testing process for prostate cancer patients treated at a multi-disciplinary uro-oncology practice. Methods: Data was retrospectively reviewed for 561 prostate cancer patients seen in a multi-disciplinary uro-oncology clinic since January 2017. Prior to January, 1, 2019 genetic testing was recommended to patients based on NCCN guidelines, and swabs for testing were procured off-site less than 1 mile from the clinic (n=107). After January, 1, 2019 genetic testing was recommended based on the guidelines set forth by the Philadelphia consensus conference, and swabs for testing were procured at the clinic itself (n=454). Results: A statistically significant increase in compliance with genetic testing was observed after the implementation of an on-site, guideline-based testing process. Patient compliance with genetic testing increased from 33.6% to 96.5%. The time to receive the genetic test results (calculated as the time between referral for genetic testing and obtaining the test results) was also significantly improved from 38 days to 21 days. Conclusions: The implementation of an on-site, guideline-based genetic testing model for prostate cancer patients significantly improved compliance with genetic testing to 96.5% and decreased the time to receive genetic test results by 17 days. Overall, adopting a guide-line based model with on-site genetic testing has the potential to significantly improve the detection rate for pathogenic and actionable mutations, increase the utilization of targeted therapies, and increase cascade testing to include at-risk family members.

Outcomes of men with prostate cancer managed with active surveillance and tested with clinical cell-cycle risk score

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Background: The indolent nature of many prostate cancers (PC) makes some men eligible to undergo active surveillance (AS) rather than immediate definitive treatment. Accurate risk classification is critical for selection of appropriate candidates for AS. The clinical cell-cycle risk (CCR) score, a combined clinical and molecular score, provides improved prognostic information about tumor aggressiveness over clinical parameters alone. This study aimed to evaluate the clinical outcomes of men with low-risk PC by NCCN guidelines and CCR score who selected AS. Methods: This study retrospectively reviewed men with localized PC who received CCR testing (2013-2017) and had low-risk disease according to NCCN guidelines and CCR score (N = 664). Low-risk by CCR score was defined as having a risk of disease-specific mortality < 3.2%. Men selected AS (no definitive treatment within 6 months of diagnosis) or underwent immediate definitive treatment. Durability of AS was evaluated beginning from diagnosis. Clinical outcomes were determined by reporting adverse events (biochemical recurrence (BCR), progression to metastasis as confirmed by radiographic imaging, prostate cancer specific mortality). Results: In this study, 547 men (82%) selected AS (median follow-up time 2.2 years [1.5, 3.1]). Of those managed by AS, two (0.4%) men experienced an adverse event. One man experienced BCR 3.7 years after diagnosis, and the other experienced metastasis 0.9 years after diagnosis. There were no reported cases of disease-specific mortality. The probability of remaining on AS for 3 years was 69.6%. Common reasons for exiting AS were patient choice (27.1%), increase in Gleason score (23.3%), and change in prostate specific antigen (PSA) (10.5%). Of those patients that left AS due to change in PSA (N = 14), only 4 exhibited a clinically significant increase in PSA ( > 10 ng/mL). Conclusions: The majority of men with molecularly-confirmed (CCR), NCCN low-risk PC selected AS in both academic and community settings. The incidence of metastatic disease or BCR after definitive treatment for disease progression was rare. The majority of men who selected AS remained on AS for the duration of the study.

Clinical Utility of Gene Expression Classifiers in Men With Newly Diagnosed Prostate Cancer

PURPOSE

Tissue-based gene expression classifiers (GECs) may assist with management decisions in patients with newly diagnosed prostate cancer. We sought to assess the current use of GEC tests and determine how the test results are associated with primary disease management.

METHODS

In this observational study, patients diagnosed with localized prostate cancer were tracked through the Michigan Urological Surgery Improvement Collaborative registry. The utilization and results of three GECs (Decipher Prostate Biopsy, Oncotype DX Prostate, and Prolaris) were prospectively collected. Practice patterns, predictors of GEC use, and effect of GEC results on disease management were investigated.

RESULTS

Of 3,966 newly diagnosed patients, 747 (18.8%) underwent GEC testing. The rate of GEC use in individual practices ranged from 0% to 93%, and patients undergoing GEC testing were more likely to have a lower prostate-specific antigen level, lower Gleason score, lower clinical T stage, and fewer positive cores (all P < .05). Among patients with clinical favorable risk of cancer, the rate of active surveillance (AS) differed significantly among patients with a GEC result above the threshold (46.2%), those with a GEC result below the threshold (75.9%), and those who did not undergo GEC (57.9%; P < .001 for comparison of the three groups). This results in an estimate that, for every nine men with favorable risk of cancer who undergo GEC testing, one additional patient may have their disease initially managed with AS. On multivariable analysis, patients with favorable-risk prostate cancer who were classified as GEC low risk were more likely to be managed on AS than those without testing (odds ratio, 1.84; P = .006).

CONCLUSION

There is large variability in practice-level use and GEC tests ordered in patients with newly diagnosed, localized prostate cancer. In patients with clinical favorable risk of cancer, GEC testing significantly increased the use of AS. Additional follow-up will help determine whether incorporation of GEC testing into initial patient care favorably affects clinical outcomes.

Prostatectomy-based validation of combined urine and plasma test for predicting high grade prostate cancer

BACKGROUND

Distinguishing between low- and high-grade prostate cancers (PCa) is important, but biopsy may underestimate the actual grade of cancer. We have previously shown that urine/plasma-based prostate-specific biomarkers can predict high grade PCa. Our objective was to determine the accuracy of a test using cell-free RNA levels of biomarkers in predicting prostatectomy results.

METHODS

This multicenter community-based prospective study was conducted using urine/blood samples collected from 306 patients. All recruited patients were treatment-naïve, without metastases, and had been biopsied, designated a Gleason Score (GS) based on biopsy, and assigned to prostatectomy prior to participation in the study. The primary outcome measure was the urine/plasma test accuracy in predicting high grade PCa on prostatectomy compared with biopsy findings. Sensitivity and specificity were calculated using standard formulas, while comparisons between groups were performed using the Wilcoxon Rank Sum, Kruskal-Wallis, Chi-Square, and Fisher's exact test.

RESULTS

GS as assigned by standard 10-12 core biopsies was 3 + 3 in 90 (29.4%), 3 + 4 in 122 (39.8%), 4 + 3 in 50 (16.3%), and > 4 + 3 in 44 (14.4%) patients. The urine/plasma assay confirmed a previous validation and was highly accurate in predicting the presence of high-grade PCa (Gleason ≥3 + 4) with sensitivity between 88% and 95% as verified by prostatectomy findings. GS was upgraded after prostatectomy in 27% of patients and downgraded in 12% of patients.

CONCLUSIONS

This plasma/urine biomarker test accurately predicts high grade cancer as determined by prostatectomy with a sensitivity at 92-97%, while the sensitivity of core biopsies was 78%.

A Multi-Center Prospective Study to Validate an Algorithm Using Urine and Plasma Biomarkers for Predicting Gleason ≥3+4 Prostate Cancer on Biopsy

Background: Unnecessary biopsies and overdiagnosis of prostate cancer (PCa) remain a serious healthcare problem. We have previously shown that urine- and plasma-based prostate-specific biomarkers when combined can predict high grade prostate cancer (PCa). To further validate this test, we performed a prospective multicenter study recruiting patients from community-based practices.

Patients and Methods: Urine and plasma samples from 2528 men were tested prospectively. Results were correlated with biopsy findings, if a biopsy was performed as deemed necessary by the practicing urologist. Of the 2528 patients, biopsy was performed on only 524 (21%) patients.

Results: Of the 524 patients, Gleason≥3+4 PCa was found in 161 (31%) and Gleason ≥4+3 was found in 62 (12%) of the patients.

The urine/plasma biomarkers algorithm showed sensitivity and specificity of 75% and 69% for predicting Gleason ≥3+4. However, upon incorporating prostate size and prior history of biopsy in the algorithm, we achieved a sensitivity between 97% and 86% and a specificity between 36% and 57%, dependent on the used cut-off point. Sensitivity for predicting PCa Gleason ≥4+3 was between 96% and 99% and specificity between 59% and 37%, dependent on the cut-off point. Diagnosis of Gleason ≥3+4 was missed in 1% to 3% of tested patients and of Gleason ≥4+3 in 0.2% to 1%.

Conclusion: This test when integrated with prostate volume and the prior prostate biopsy enhance the sensitivity and specificity for predicting the presence of high grade prostate cancer with negative predictive value (NPV) of 90% to 97% for Gleason ≥3+4 and between 98% to 99% for Gleason ≥4+3.

The clinical and economic implications of specimen provenance complications in diagnostic prostate biopsies

PURPOSE

Inaccurate diagnoses of prostate cancer can result from transposition or contamination of patient biopsy specimens, which are known as specimen provenance complications. We assessed the clinical and economic burden of specimen provenance complications in prostate biopsies in the United States.

MATERIALS AND METHODS

We performed a comprehensive, systematic review of the literature to approximate the effect of specimen provenance complications on direct medical costs, patient QALYs and medicolegal costs. Data were extracted from published studies on specimen provenance complications rates, prostate cancer treatment efficacy, treatment cost, litigation/settlement costs after false diagnoses of prostate biopsies and patient quality of life. Sensitivity analysis was done to identify factors that most influenced the outcomes and assess the robustness of the findings.

RESULTS

Of the estimated 806,251 primary and secondary prostate biopsies performed annually in the United States 20,322 specimen provenance complications were projected to result in 4,570 clinically meaningful false diagnoses and an expected loss of 634 QALYs. The total burden of specimen provenance complications was projected to exceed $879.9 million or $3,776 per positive cancer diagnosis. This estimate was most sensitive to the indemnity cost per false-positive case and the rate of transpositions at independent reference laboratories.

CONCLUSIONS

The societal burden of specimen provenance complications in patients who undergo prostate biopsy exceeds $880 million annually in the United States. This analysis framework may be useful as policy makers, health organizations and researchers seek to decrease false diagnoses of prostate cancer and the consequent effects of delayed or unnecessary treatment. Further study is warranted to quantify the economic burden among additional diseases.

Histotripsy of the prostate: dose effects in a chronic canine model

OBJECTIVES

To develop the technique of histotripsy ultrasound therapy as a noninvasive treatment for benign prostatic hyperplasia and to examine the histotripsy dose-tissue response effect over time to provide an insight for treatment optimization. We have previously demonstrated the feasibility of prostate histotripsy fractionation in a canine model.

METHODS

Various doses of histotripsy were applied transabdominally to the prostates of 20 canine subjects. Treated prostates were then harvested at interval time points from 0 to 28 days and assessed for histologic treatment response.

RESULTS

The lowest dose applied was found to produce only scattered cellular disruption and necrosis, whereas higher doses produced more significant regions of tissue effect that resulted in sufficient fractionation of tissue so the material could be voided with urination. Urethral tissue was more resistant to the lower histotripsy doses than was parenchymal tissue. Treatment of the urethra at the lowest doses appeared to heal, with minimal long-term sequelae.

CONCLUSIONS

Histotripsy was effective at fractionating parenchymal and urethral tissue in the prostate, in the presence of a sufficient dose. Further development of this technique could lead to a noninvasive method for debulking the prostate to relieve symptoms associated with benign prostatic hyperplasia.

Body composition and serum prostate-specific antigen: review and findings from Flint Men's Health Study

Recent studies have suggested that obesity is associated with lower serum prostate-specific antigen levels, perhaps influencing the recommendation for prostate biopsy and potentially explaining part of the observed poorer prognosis among obese men. African-American men have the greatest rates of prostate cancer and are more likely to die of the disease, making early detection a priority in this group. We present findings from the Flint Men's Health Study, a study of African-American men, that are consistent with most studies suggesting that overweight men have prostate-specific antigen levels that are 0.15 to 0.30 ng/mL lower than those who are not overweight. We have coupled our results with a systematic review of publications in this area.

Targeting CCL2 with systemic delivery of neutralizing antibodies induces prostate cancer tumor regression in vivo

The identification of novel tumor-interactive chemokines and the associated insights into the molecular and cellular basis of tumor-microenvironment interactions have continued to stimulate the development of targeted cancer therapeutics. Recently, we have identified monocyte chemoattractant protein 1 (MCP-1; CCL2) as a prominent regulator of prostate cancer growth and metastasis. Using neutralizing antibodies to human CCL2 (CNTO888) and the mouse homologue CCL2/JE (C1142), we show that treatment with anti-CCL2/JE antibody (2 mg/kg, twice weekly i.p.) attenuated PC-3Luc-mediated overall tumor burden in our in vivo model of prostate cancer metastasis by 96% at 5 weeks postintracardiac injection. Anti-CCL2 inhibition was not as effective as docetaxel (40 mg/kg, every week for 3 weeks) as a single agent, but inhibition of CCL2 in combination with docetaxel significantly reduced overall tumor burden compared with docetaxel alone, and induced tumor regression relative to initial tumor burden. These data suggest an interaction between tumor-derived chemokines and host-derived chemokines acting in cooperation to promote tumor cell survival, proliferation, and metastasis.

Glutamine tract length of human androgen receptors affects hormone-dependent and -independent prostate cancer in mice

The androgen receptor (AR) is involved in the initiation and progression of prostate cancer and its transition to androgen independence. Genetic variation in AR may contribute to disease risk and has been studied for a polymorphic N-terminal glutamine (Q) tract that shows population heterogeneity. While the length of this tract is known to affect AR in vitro, association with disease is complicated by genetic and environmental factors that have led to discordant epidemiological findings. To clarify the effect of Q tract polymorphism on prostate cancer, we created mice bearing humanized AR genes (h/mAr) varying in Q tract length. ARs with short Q tracts (12Q), which are transcriptionally more active, induce earlier disease in the transgene-induced TRAMP prostate cancer model than alleles with median (21Q) or long (48Q) tracts. Disease length varies within each genotype, with greater differentiation and AR expression in slower growing tumors. Remarkably, following androgen ablation, Q tract length has effects that are also allele-dependent and in directions opposite to those in hormone intact mice. Differences in AR activity conferred by Q tract length thus appear to direct distinct pathways of androgen-independent as well as androgen-dependent progression, and highlight substantial risk that may be associated with alterations in the androgen axis. This AR allelic series in humanized mice provides an experimental paradigm to dissect the role of AR in prostate cancer initiation and progression, to model response to treatment and to test therapies targeted specifically to the human AR.

Analysis of three-dimensional ultrasound Doppler for the detection of prostate cancer

OBJECTIVES

To investigate the relative effectiveness of Doppler ultrasound quantitative measures in discriminating prostate cancer from normal prostate tissue. The true locations of prostate cancer within these prostates were determined by histologic examination after radical prostatectomy.

METHODS

Three-dimensional Doppler ultrasound data were acquired from 39 men before radical prostatectomy. The removed prostates were sectioned and all cancerous regions in each prostate were identified on whole-mount hematoxylin-eosin-stained slides. The ultrasound and histologic data were then spatially registered. Biopsy results were simulated on a grid of potential sites within each prostate. Along each simulated biopsy site, the amount of cancer was computed from the hematoxylin-eosin-identified cancerous regions and the peak speed-weighted pixel density (SWD) was compared.

RESULTS

By selecting the biopsy sites with higher associated SWDs within each sextant, the probability of having at least one positive biopsy within a prostate increased from 75% if the SWD was ignored to 85% if only the top 15% of potential biopsy sites in each sextant were selected. This trend was seen within each sextant individually as well.

CONCLUSIONS

Doppler ultrasound provides discriminatory information for prostate cancer using the SWD. Translating this into a practical strategy that might improve the yield of prostate biopsy remains under development. The results of our study indicate that biopsying regions of high Doppler color could potentially increase the cancer yield to a small degree and improve the accuracy of the biopsy results. These results also objectively verify previous visual studies suggesting a modest improvement with the use of color Doppler.

Decreased galectin-3 expression in prostate cancer

BACKGROUND

Galectin-3 is a carbohydrate-binding protein whose level of expression has been shown to be correlated with metastatic potential in a number of different tumor types. The purpose of this investigation was to examine galectin-3 expression in several tumorigenic and nontumorigenic prostate cell lines and prostate tissue samples.

METHODS

The expression of galectin-3 in cell lines and tissue samples was evaluated by tissue immunohistochemistry and Western blot analysis.

RESULTS

Human cell lines PC-3M, PC-3, DU-145, PrEC-1, and MCF10A demonstrated the presence of galectin-3. Galectin-3 was not detected in TSU-pr1 and LNCaP by Western blot analysis. We furthered our studies by examining a series of human prostate tissue samples for expression of galectin-3. Overall, approximately 60-70% of the normal tissue examined demonstrated heterogenous expression of galectin-3. In stage II tumors, however, there was a dramatic decrease in galectin-3 expression in both PIN and tumor sections, with only 10.5% (2/19) of these samples expressing this protein. Stage III tumors also demonstrated a decreased expression of galectin-3, although this downregulation was not as dramatic, with 35% of PIN samples and 52% of tumor tissue expressing galectin-3 (P < 0.01).

CONCLUSIONS

These data demonstrate that galectin-3 is downregulated in prostate cancer. The altered downregulation pattern of galectin-3 observed between tumor stages suggests different roles for galectin-3 in the progression of prostate cancer.

Sex cord-stromal tumors of the testis with entrapped germ cells: a lesion mimicking unclassified mixed germ cell sex cord-stromal tumors

The authors describe 10 sex cord-stromal tumors of the testis that incorporated germ cells, thereby mimicking the unclassified type of mixed germ cell sex cord-stromal tumor (MGCSCST). These neoplasms occurred in patients from 3 to 48 years old (mean age, 26 years) who presented with testicular masses. On microscopic examination, nine tumors had a combination of tubular and cord-like arrangements of sex cord cells with transition to spindle-shaped tumor cells. They were diagnosed as either unclassified sex cord-stromal tumors (n = 5) or Sertoli-stromal cell tumors (n = 4). One tumor was a pure Sertoli cell tumor. The admixed germ cells were usually at the periphery and in clusters, but occasionally were in the center or more diffuse. In nine patients the germ cells resembled spermatogonia, having round nuclei with uniform, dusty chromatin and inconspicuous or small nucleoli. None of these cells stained with a variety of markers used for neoplastic germ cells, and in one case in which the non-neoplastic Sertoli cells were strongly reactive for inhibin but the neoplastic Sertoli cells were not, all the germ cells within the tumor occurred adjacent to inhibin-positive Sertoli cells. With static cytophotometry, a diploid deoxyribonucleic acid content was found in these germ cells in the two investigated cases. In one case the germ cells had the morphologic appearance of seminoma cells and they stained positively for the markers of neoplastic germ cells. This case was interpreted as a "collision" tumor between a Sertoli cell tumor and a seminoma. The authors conclude that sex cord-stromal tumors with entrapped germ cells of the testis are more common than unclassified MGCSCSTs--a bona fide testicular example of which has not been seen by any of the authors.

Rapid ("warm") autopsy study for procurement of metastatic prostate cancer

In this report, we describe the distribution of metastases from 14 patients who had hormone-refractory adenocarcinoma of the prostate and agreed while alive to undergo directed autopsies after their deaths. These autopsies were undertaken specifically to document the distribution of metastases, characterize tumors phenotypically and immunohistochemically, harvest fresh and snap frozen tumor and normal control tissues suitable for molecular examination, and establish cell lines via passages through generations of severe combined immunodeficient and athymic mice. Achievement of these goals was obtained through the development of a multidisciplinary team approach. Team members included a medical oncologist, pathologists, urologists, and researchers. The autopsy and tissue procurement teams were available on a round-the-clock basis. The tissues harvested from these autopsies yielded high-quality tumor samples, as evidenced by excellent preservation seen by light microscopy, strong prostate-specific antigen immunostaining, and the successful development of xenografts. The development and expansion of this program represent a valuable resource for molecular and clinical researchers.

Relationship and significance of greatest percentage of tumor and perineural invasion on needle biopsy in prostatic adenocarcinoma

Serum prostate-specific antigen (PSA) levels and the biopsy Gleason sum are used along with clinical staging to predict prostatectomy pathology results for men with localized prostate cancer. The additional predictive value of perineural invasion (PNI) in pretreatment prostate needle biopsies for evaluating tumor stage in this setting is controversial. The current study evaluates the independent predictive value of PNI for tumor staging in a cohort of 632 men who underwent radical retropubic prostatectomies for clinically localized adenocarcinoma of the prostate between the years 1994 and 1998. None of these men received hormonal or radiation therapy before surgery. In addition to the Gleason sum, biopsy results contained detailed information regarding tumor burden: 1) total number of biopsy cores involved by adenocarcinoma, 2) greatest percentage of any single biopsy involved by prostate carcinoma (GPC), and 3) total percentage of cancer added over all cores (TPC). The presence or absence of any PNI was recorded. Pretreatment factors were analyzed in a univariate and multivariate fashion to determine their predictive value using the TNM tumor stage (pT2 vs pT3) and the modified tumor staging system, which includes surgical margin status (pT2 vs pT3 or positive surgical margin) as end points. Univariate analysis revealed a significant association between pT3 disease and several preoperative factors including age, Gleason sum, serum PSA, digital rectal examination, PNI, GPC, TPC, and the total number of positive cores (p <0.01). Multivariate analysis indicated that serum PSA, Gleason sum, age, and GPC contributed significantly to predicting pT3 disease with odds ratios of 2.7 (95% CI, 1.7-4.3), 2.3 (95% CI, 1.7-3.1), 1.7 (95% CI, 1.1-2.7), and 1.7 (95% CI, 1.4-2.1) respectively. PNI was significant in multivariate analysis only when GPC and TPC were not considered, due to a significant interaction between GPC and PNI (p <0.0001, Wilcoxon's rank sum test). These predictive factors showed a similar relationship to adverse pathology when an alternative definition of adverse pathology was used that included positive surgical margins (pT3 or any positive margin). In the interaction between GPC and PNI, GPC was more significant than PNI in predicting pT3 disease. However, PNI added additional information when adverse pathology was defined more broadly as pT3 or any positive margin.

Characteristics of nonmalignant and malignant human prostate in organ culture

Prostate tissue was obtained from 52 radical prostatectomies immediately upon surgery. From each specimen, a small piece of tissue was fixed in 10% buffered formalin and used for histology, cytokeratin staining, staining with the antibodies to the proliferation-associated antigen (Ki-67), and histochemical evaluation of the epithelial-stromal basement membrane. A second piece was used for the isolation of epithelial cells and stromal cells in monolayer culture. The remainder of each specimen was cut into cubes (approximately 1 mm on a side) and incubated in organ culture for up to 20 days. At the end of the incubation period, tissue was fixed in 10% buffered formalin and examined as described above with zero-time tissue. These studies showed that normal epithelial and stromal elements survived in organ culture in the presence of a serum-free medium containing a mixture of growth factors (epidermal growth factor, insulin, pituitary extract, and dihydrotestosterone). In many of the tissues examined at 4 days, individual glands resembled those seen immediately after surgery, with a single layer of basal epithelial cells and a layer of secretory cells above. By Day 8, the secretory epithelium was lost in many places and basal cells proliferated to fill in the lumens of the glands. All of the nonmalignant glands were reactive with the anti-cytokeratin antibody (K903), and there was a large increase in the number of cells staining for Ki-67 as compared with zero-time tissue. Staining with the Periodic Acid Schiff (PAS) and PAS-methenamine silver (PASME) reagents revealed an intact basement membrane around virtually all of the epithelial structures. The basement membrane appeared to be thickened in some areas. In places where a gland was cut during the processing of the tissue, epithelial cells migrated out of the gland and covered the cut surface of the tissue piece. There was no detectable basement membrane separating the epithelium from the stroma at these sites. Whereas nonmalignant epithelial cells were preserved in the growth factor- and dihydrotestosterone-supplemented culture medium, most of the malignant cells rapidly lysed under the same conditions. However, when phorbol myristate acetate was included in the culture medium, many of the tumor cells remained viable. This was seen with the more well-differentiated tumors as well as with tumors that were highly anaplastic. All of the tumor cells were nonreactive with anti-cytokeratin antibody, and only a few cells stained for Ki-67. The basement membrane surrounding malignant cells was thin and, in places, appeared to be discontinuous. Where malignant glands were cut in the processing of the tissue, cells did not migrate out over the cut surface. In summary, this study identifies culture conditions for the successful maintenance of human prostate tissue for several days in organ culture. Histological/histochemical features that distinguish nonmalignant and malignant tissue are present in this model.

Transitional cell carcinoma in situ of the seminal vesicles: 8 cases with discussion of pathogenesis, and clinical and biological implications

PURPOSE

Mucosal migration of transitional cell carcinoma in situ is a potential mechanism for multifocal lower tract disease.

MATERIALS AND METHODS

The clinical course and pathological studies of 8 cases of carcinoma in situ are reviewed in detail.

RESULTS

The pattern of disease of carcinoma in situ of seminal vesicle provides circumstantial evidence for mucosal migration of cancer from a bladder or prostatic urethral origin.

CONCLUSIONS

A monoclonal origin of bladder cancer combined with mucosal spread of carcinoma in situ suggests that incomplete destruction of carcinoma in situ may adversely affect long-term results by permitting extension into the distal ureters, prostatic duct or seminal vesicles. Protracted intravesical treatment of carcinoma in situ without complete elimination of the disease allows the natural history of mucosal spread to become evident.

Cystic renal masses: a reevaluation of the usefulness of the Bosniak classification system

RATIONALE AND OBJECTIVES

We evaluated the utility of the Bosniak system for classifying cystic renal masses on computed tomography (CT) scans.

METHODS

The CT scans of 20 patients with 24 cystic renal masses that were subsequently surgically removed or biopsied were reviewed retrospectively. Masses were categorized using the Bosniak system and were correlated with the pathology results.

RESULTS

The final pathology results of the cystic renal masses were as follows: Seven of seven category I lesions were benign, one of five category II lesions was benign, zero of four category III lesions were benign, and zero of six category IV lesions were benign. Neither of two unclassifiable cystic lesions were benign. The average enhancement of lesions in categories II, III, and IV was 6.3, 2.3, and 27.6 Hounsfield units (H), respectively. The two uncategorizable lesions had a mean enhancement of 26.8 H.

CONCLUSION

The results of our study serve to underscore some limitations of the Bosniak classification system because most of our category II and all of our category III lesions were malignant, suggesting that minimally complex cystic renal masses may contain malignant cells. Contrast enhancement of less than 10 H was demonstrated in lesions in categories II and III.

Necrotizing fasciitis: a fatal outcome following minor trauma. Case report and literature review

The death of a young healthy man, 11 days after he sustained minor trauma, illustrates the potential disaster of undiagnosed necrotizing fasciitis. Difficulty in early diagnosis often arises because the skin is initially spared and only later becomes secondarily involved. In this case, because of the lack of external manifestations, the diagnosis of necrotizing fasciitis was not considered until the postmortem examination. Necrotizing fasciitis should be considered a potentially serious problem that can follow minor trauma and eventually lead to death. The need for a high index of suspicion to make this diagnosis, along with the medicolegal implication of a diagnosis of necrotizing fasciitis, are both addressed in this report. Also of note is the fact that this patient was treated with nonsteroidal antiinflammatory drugs for pain and inflammation, which has recently been reported to be associated with an increased incidence of fulminant evolution of necrotizing fasciitis.