Diagnostic terminology for benign/low-risk tumors on renal cytology

Biopsy of benign and low-risk tumors of the kidney can be grouped into three distinct categories with different levels of risk, and the suggested diagnoses of these tumors should be tailored to their respective category.

Modified Bethesda criteria for thyroid aspirates significantly decrease nondiagnostic rates without decreasing sensitivity

INTRODUCTION

Previous studies suggest that the adequacy rate of thyroid aspirates can be improved by altering the adequacy criteria of the Bethesda System. We sought to measure the performance of these altered criteria in a prospective fashion.

MATERIALS AND METHODS

Over a 6-year period, cases with 1 to 59 follicular cells were prospectively classified as "nondiagnostic, favor benign" or "scant but adequate". "Scant but adequate" cases were classified as either benign (Bethesda category 2) or atypia of undetermined significance (AUS) (Bethesda category 3). Bethesda category 3 cases were referred for Afirma testing (Veracyte, San Francisco, CA).

RESULTS

Of 5147 cases, 131 (3%) were classified as "nondiagnostic, favor benign"; 45 (65%) of these had follow-up with a risk of malignancy of 2.6%. Additionally, 436 (8%) of all 5147 cases were classified as "scant but adequate" and "benign"; 49 (11%) of these had follow-up with a risk of malignancy of 0%. Lastly, 197 (4%) of all 5147 cases were classified as "scant but adequate" with AUS; 177 (90%) of these 197 cases had an adequate Afirma result. The "suspicious" rate was not significantly different than that of cases classified as "adequate" and AUS (Bethesda category 3 and 4) (35 of 197 [18%] versus 140 of 848 [17%] P = 0.67), and there was no significant difference in the risk of malignancy for these 2 categories ("scant but adequate" 9 of 18, "adequate" 50% versus 27 of 85, 32%, P = 0.10). Overall, the modified Bethesda criteria reduced the nondiagnostic rate from 22% to 10% (P <0.001) without lowering the sensitivity of the test.

CONCLUSIONS

Modified Bethesda adequacy criteria can significantly lower nondiagnostic rates without lowering sensitivity.

Risk of malignancy in renal biopsy: A review

The risks of malignancy for cytologic categories in renal biopsy specimens differ from the risks in most other sites. There are obvious areas in which cytopathologists can do better at classifying these cases, and the routine use of immunohistochemistry and core-needle biopsy may improve the accuracy of the classification of these specimens.

Low-risk oncocytic renal neoplasm: A useful cytologic diagnosis

The proposed diagnostic category of “low‐risk oncocytic renal neoplasm” consists of both oncocytomas and a subset of chromophobe renal cell carcinomas but has a 5‐year survival of at least 95%–100%.

Sclerosis of the clavicle––A challenging diagnosis

Condensing osteitis of the clavicle is a rare benign disease described as an increase in bone density at the medial end of the clavicle. Its clinical and radiographic presentation can frequently be equivocal and tissue sampling is necessary for diagnostic confirmation. Here we present the case of a 29-year-old female with condensing osteitis of the right medical clavicle, who remained undiagnosed for many years despite obtaining imaging studies and undergoing an initial biopsy. This disease presents oftentimes a challenging diagnosis due to its imaging features overlapping with many benign and malignant bone lesions. A qualified multidisciplinary team with expertise in rare bone conditions becomes oftentimes essential to arrive at an accurate diagnosis.

Cytology should create structured data sets without using synoptic reporting

Structured data sets can be created from cytology reports without the addition of synoptic reports using either natural language processing or minor changes to laboratory information systems structure.

Radiation and Androgen Deprivation Therapy With or Without Docetaxel in the Management of Nonmetastatic Unfavorable-Risk Prostate Cancer: A Prospective Randomized Trial

Although docetaxel is not recommended when managing men with unfavorable-risk prostate cancer (PC) given negative or inconclusive results from previous randomized trials, unstudied benefits may exist.

Radiation and androgen deprivation therapy with or without docetaxel in the management of non-metastatic unfavorable-risk prostate cancer: A prospective randomized trial

5011

Background: For men with unfavorable-risk non-metastatic (M0) prostate cancer (PC) the addition of docetaxel to radical prostatectomy (RP) or radiation therapy (RT) and androgen deprivation therapy (ADT) has been studied in 6 randomized controlled trials with negative or inconclusive results. Specifically, an overall survival (OS) benefit with a non-significant reduction in PC-specific mortality (PCSM) has been observed in two of the 6 studieswhere > 80% of the patients had high-grade PC. A plausible hypothesis for the OS benefit and a non-significant reduction in PCSM is that docetaxel reduces PCSM in the small subset of men with low prostate-specific antigen (PSA)-producing, high-grade PC that may be resistant to conventional ADT while also reducing non-PCSM by reducing death from RT-induced cancers. Given that docetaxel even at low doses (i.e. 20 mg/m2) is a potent radiosensitizer,it is plausible that it can sterilize cells that survive RT-induced damage and later develop into RT-induced cancers. Therefore, while docetaxel is not recommended when managing men with unfavorable-risk prostate cancer given inconclusive results from prior randomized trials, unstudied benefits may exist. Methods: This multicenter international randomized phase 3 trial (National Clinical Trial # 00116142) assigned 350 men with T1c-4N0M0 unfavorable-risk PC to receive ADT+RT and Docetaxel (60 mg/m2 q3 weeks for 3 cycles before RT and 20 mg/m2 weekly during RT) versus ADT+RT (1:1 ratio). Collection of data at each follow-up visit on second cancer incidence and survival status was recorded. We evaluated the treatment effect of adding docetaxel to ADT+RT on the primary endpoint of OS and the incidence of RT-induced cancers and explored whether the treatment effect impacted OS differed differently within PSA subgroups ( < 4, > 20 versus 4-20 ng/mL) using the interaction test for heterogeneity adjusted for age and known PC prognostic factors. Results: After a median follow-up of 10.2 years, 89 men died (25.43%); of these 42 from PC (47.19%). While OS was not significantly increased on the docetaxel arm [restricted mean survival time over 10-years was 9.11 versus 8.82 years with a difference of 0.29 (95% CI: -0.19, 0.76) years (p = 0.22)], significantly fewer RT-induced cancers were observed [10-year estimates: 0.61% versus 4.90%: age-adjusted HR of 0.13: 95% CI: 0.02, 0.97; p = 0.046]. For men with a PSA < 4 ng/mL versus 4-20 ng/mL the treatment effect of adding docetaxel to ADT+RT on OS differed significantly [Adjusted HR: 0.27, 1.51; pinteraction = 0.047] due to less PCSM on the docetaxel arm [0/13 (0.00%) versus 4/14 (28.57%)] among men with PSA < 4 ng/mL. Conclusions: Adding docetaxel to ADT+RT did not prolong OS in men with unfavorable-risk PC, but decreased RT-induced cancer incidence, and may prolong OS in the subgroup of men with a PSA < 4 ng/mL by reducing PCSM. Clinical trial information: NCT00116142.

Prostate-specific antigen nadir and testosterone level at prostate-specific antigen failure following radiation and androgen suppression therapy for unfavorable-risk prostate cancer and the risk of all-cause and prostate cancer-specific mortality

BACKGROUND

Although both PSA nadir (PSAn) and testosterone levels at PSA failure are known prognostic factors in men undergoing radiation therapy (RT) and androgen deprivation therapy (ADT) for unfavorable-risk prostate cancer (PC), it is unclear whether their prognostic significance is independent or overlapping.

METHODS

Seventy-five men treated with RT with or without 6 months of ADT for unfavorable-risk nonmetastatic PC enrolled in 2 prospective clinical trials between 1986 and 2001 formed the study cohort. Competing risks and Cox multivariable regression were used to assess whether low versus normal serum testosterone at the time of PSA failure and higher PSAn after initial therapy were independently associated with the risk of PC-specific (PCSM) and all-cause mortality (ACM) adjusting for PC prognostic factors.

RESULTS

After a median follow-up of 15.34 years (interquartile range, 6.66-16.88 years), there were 53 deaths (73.3%): 30 (56.6%) were from PC. Low testosterone at PSA failure was significantly associated with an increased risk of PCSM (adjusted HR [AHR], 7.77; 95% CI, 1.14-52.99; P = .04) and ACM (AHR, 3.01; 95% CI, 1.01-8.96; P = .05), as was higher PSAn (PCSM AHR, 1.03; 95% CI, 1.01-1.05; P < .01; ACM AHR, 1.04; 95% CI, 1.02-1.07; P < .01), although the prognostic significance of PSAn was only noted in men with a normal testosterone at PSA failure.

CONCLUSIONS

Low testosterone level at PSA failure in high-risk patients with PC treated with RT is associated with increased PCSM and ACM risk. In men with normal testosterone levels at the time of PSA failure, an elevated PSAn was associated with worse PCSM and ACM risk.

LAY SUMMARY

This study investigates whether the prostate-specific antigen (PSA) nadir and normal versus low testosterone at the time of PSA failure provide mutually exclusive or overlapping prognostic information following treatment with radiation and androgen deprivation therapy for unfavorable-risk patients with prostate cancer using data from 2 prospective clinical trials. It was found that both provided prognostic information; however, higher PSA nadir was only found to be of prognostic significance in men with normal testosterone levels at PSA failure.

Improving Reporting of Tumor Size in Synoptic Reports

CONTEXT.—

Tumor size is an important prognostic feature in many synoptic reports. The best format to report this feature is not clearly defined.

OBJECTIVE.—

To define formatting features that impact the significance of tumor size.

DESIGN.—

We reviewed multiple formatting features of tumor size in synoptic reports and correlated them with size distribution, reproducibility, and other pathologic features.

RESULTS.—

Reporting tumors in millimeters rather than centimeters was more precise because of reduced rounding error and was significantly more reproducible (P = .01). Tumor sizes where the pathologist was concerned that the size may be underestimated are associated with significantly higher tumor N stage than tumors of similar size that are not so identified. Reported tumor sizes in multifocal tumors are also associated with significantly higher N stage than unifocal tumors of the same size.

CONCLUSIONS.—

Tumor sizes should be reported in millimeters, and when tumors are reported as either "at least" a specific size or as "multifocal" this information should also be recorded because these sizes likely underestimate the true biologic potential of the tumor.

High-grade urothelial carcinoma with hypochromatic chromatin in urine cytology

INTRODUCTION

Some high-grade urothelial carcinomas (UCs) in urine cytology have hypochromatic chromatin, but the incidence and criteria for diagnosis are not well described.

MATERIALS AND METHODS

Urine cytology cases with biopsy follow up were reviewed.

RESULTS

Cytospin preparations from 331 cases with biopsy follow up (230 benign/low-grade UC, 101 malignant) were reviewed. There were no false-positive cases. Cases with malignant cells with hypochromatic chromatin were identified in a total of 17 cases (16.8% of all malignancies). These comprised 2 carcinoma in situ, 11 high-grade papillary UC, 3 invasive UC, and 1 adenocarcinoma. Sixteen of 93 high-grade UCs (17.2%) had cells with hypochromatic chromatin. These cells were the only type of malignant cell in 4 of 101 cases (4.0%). All cases had cells with high nuclear-to-cytoplasmic ratios and markedly indented and irregular nuclear membranes that could be identified on both cytology and subsequent histology.

CONCLUSIONS

Malignant urothelial cells in urine cytology with hypochromatic chromatin can be present in 17% of cases and can be diagnosed as "positive for malignancy" based on their high nuclear-to-cytoplasmic ratio, and markedly indented and irregular nuclear membranes.

Thyroid FNA: Is cytopathologist review of ultrasound features useful?

Cytopathologist review of thyroid ultrasound (US) has been proposed to be useful in diagnosis and patient triage. This review explores the implications for practicing cytopathologists of integrating US review into the thyroid fine-needle aspiration diagnosis. At present, there is no agreed-upon system for combining cytologic and US features and communicating those results as a single report. If cytologists are performing tasks that require expertise in US interpretation, then they should know and be fully conversant with US interpretation. Whether cytologists performing aspirations require expertise in US interpretation is not clear. Regardless, cytologists should avoid using US results to alter their cytologic interpretations unless they clearly communicate that this is what they are doing. An evidence-based integrated reporting system that would allow cytologists to clearly explain to other physicians exactly how they reached their interpretation might provide value beyond current standard practice.

Malignancy risk for solitary and multiple nodules in Hürthle cell-predominant thyroid fine-needle aspirations: A multi-institutional study

BACKGROUND

Hürthle cell metaplasia is common in hyperplastic nodules, particularly within the setting of lymphocytic thyroiditis (LT). The Bethesda System for Reporting Thyroid Cytopathology indicates that it is acceptable to classify Hürthle cell-predominant fine-needle aspiration (HC FNA) specimens as atypia of undetermined significance (AUS) rather than suspicious for a Hürthle cell neoplasm (HUR) within the setting of multiple nodules or known LT. The goal of the current study was to address whether this approach is justified.

METHODS

HC FNA specimens were identified and correlated with ultrasound and surgical pathology reports if available. Multinodularity was determined based on findings on macroscopic examination if imaging results were unavailable.

RESULTS

A total of 698 HC FNA specimens were identified, including 576 resected nodules, 455 of which (79%) were benign. The overall risk of malignancy for HUR was 27%, whereas the risk of malignancy for AUS was 10%. The mean size of the benign nodules was 2.1 cm on surgical resection specimens, with multiple nodules noted in 293 cases (64%) and histologic LT noted in 116 cases (25%). The mean size of the malignant nodules was 2.8 cm, with multiple nodules and histologic LT noted in 74 cases (61%) and 22 cases (18%), respectively. The malignancy rate did not differ between solitary or multiple nodules (P = .52) or in the presence or absence of LT (P = .12). However, size did significantly differ between malignant and benign nodules (P < 0.01).

CONCLUSIONS

The malignancy rate did not differ significantly in the presence of multiple nodules or LT, although the latter demonstrated a statistical trend. A diagnosis of AUS over HUR based solely on the presence of multinodularity is not warranted.

Early Versus Delayed Initiation of Salvage Androgen Deprivation Therapy and Risk of Prostate Cancer-Specific Mortality

Background: This study sought to ascertain whether there is an association between prostate cancer (PC)-specific mortality (PCSM) and timing of salvage androgen deprivation therapy (ADT) among men with short versus long prostate-specific antigen doubling times (PSA-DTs). Methods: The study cohort was selected from 206 men with localized unfavorable-risk PC randomized to radiation therapy (RT) or RT plus 6 months of ADT between 1995 and 2001. A total of 54 men who received salvage ADT for PSA failure after a median follow-up of 18.72 years following randomization defined the study cohort. The Fine-Gray competing risks regression model was used to analyze whether the timing of salvage ADT was associated with an increased risk of PCSM after adjusting for age, comorbidity, known PC prognostic factors, and previously identified interactions. Results: After a median follow-up of 5.68 years (interquartile range, 3.05-9.56) following salvage ADT, 49 of the 54 men (91%) died, of which 27 from PC (54% of deaths). Increasing PSA-DT as a continuous covariate (per month increase) was associated with a decreasing risk of PCSM (adjusted hazard ratio [HR], 0.33; 95% CI, 0.13-0.82; P=.02). Among men with a long PSA-DT (≥6 months), initiating salvage ADT later (PSA level >12 ng/mL, upper quartile) versus earlier was associated with an increased risk of PCSM (adjusted HR, 8.84; 95% CI, 1.99-39.27; P=.004), whereas for those with a short PSA-DT (<6 months; adjusted HR, 1.16; 95% CI, 0.38-3.54; P=.79) this was not true. Conclusions: Early initiation of salvage ADT for post-RT PSA failure in men with a PSA-DT of ≥6 months may reduce the risk of PCSM.

Reporting Margin Status in Synoptic Reports

PURPOSE

The format of a synoptic report can significantly affect the accuracy, speed, and preference with which a reader can retrieve information. The purpose of this study was to compare different formats for reporting margin status in synoptic reports of colonic carcinoma.

METHODS

The performance of 17 nonpathologists (cancer registrars and medical and nonmedical personnel) at identifying specific information in various formatted synoptic reports was evaluated using four computerized quizzes that measured both accuracy and speed.

RESULTS

Compared with the standard format ("Involved by invasive carcinoma" and "Uninvolved by invasive carcinoma"), reporting margins as "Free" or "Positive" was significantly faster (17%, P < .001) and significantly more accurate (99% v 98%, P = .001). Significantly more errors for the standard format were found in quiz 4 (eight of 272; 2.9%) than the prior three tests combined (nine of 816; 1.1%; P = .05). Using "Free" or "Positive" with either a list format or including bolding of all positive margins was also faster than the standard format but not any faster than simply changing the wording. All users preferred "Free" and "Positive"; no user preferred "Involved by invasive carcinoma" and "Uninvolved by invasive carcinoma."

CONCLUSION

Using "Free" and "Positive" for reporting margin status in synoptic reports is preferred by all users and results in more accurate, faster information retrieval. Errors may be related to fatigue.

Needle track seeding in renal mass biopsies

A review and analysis of the literature demonstrates that needle track seeding in renal mass biopsy has been reported 16 times. This complication occurs almost exclusively among patients with papillary renal cell carcinoma. The incidence is associated with multiple punctures of the mass, the use of core needles of ≥20 gauge, and lack of a coaxial sheath. Needle tract seeding may be associated with tumor upstaging and a worse prognosis. Fine-needle aspiration has a significantly lower rate of needle track seeding compared with large core needle biopsy (>20-gauge needle). A more formalized risk-based system for interpreting renal mass fine-needle aspiration may be useful as clinicians choose among an increasing number of therapeutic options.

Effusion cytology of epithelioid rhabdomyosarcoma

We report a case of epithelioid rhabdomyosarcoma in a pleural effusion. In contrast to most rhabdomyosarcomas in effusions, the cells presented as cohesive clusters of atypical cells with abundant eosinophilic cytoplasm which mimicked an adenocarcinoma. Immunohistochemistry was positive for epithelial membrane antigen and muscle markers and negative for keratins.

Time to PSA nadir and the risk of death from prostate cancer following radiation and androgen deprivation therapy

4

Background: Whether the time to PSA nadir (TTN) has differential prognostic value in men who reach an undetectable versus detectable PSA nadir remains unknown. Methods: Two-hundred and four men from a prospective randomized controlled trial (RCT) involving radiation therapy with or without 6 months of androgen deprivation therapy (ADT) in unfavorable risk CaP at academic or community based centers in Massachusetts, enrolled between 1995 and 2001. Adjusted hazard ratios (AHR) of the risk of CaP-specific mortality (PCSM) calculated using Fine and Gray competing risk regression. Results: After a median follow-up of 18.17 years, 160 men died; 30 (18.75%) of CaP. Amongst men with a PSA nadir ≥ 0.2 ng/ml, a TTN < median (12 months) was significantly associated with an increased PCSM-risk versus the median or more (AHR 5.07, 95% CI 2.10-12.23, p<0.001); whereas this association was not observed among men with a PSA nadir of <0.2 ng/ml, (AHR 9.9, 95% CI 0.23-433.8, p=0.23). Conclusions: Men with both a short TTN and detectable PSA nadir could be considered for entry on RCTs at a novel entry point prior to PSA failure at the time of PSA nadir to complete planned conventional ADT versus that plus agent(s) shown to improve outcomes in men with or at high risk of having castrate-resistant CaP.

Risk stratification of HIV infection for patients needing molecular confirmation with the Abbott 4th generation Architect System

BACKGROUND

Some patients need their 4^th generation HIV testing results confirmed with molecular testing after primary confirmatory testing which may not be immediately available. Further risk stratification of these patients pending the results of molecular testing may be of value not only for patient counseling but also for treatment of women in labor.

OBJECTIVES

To determine the risk of a positive test result on molecular testing for these patients.

STUDY DESIGN

The risk of a positive molecular test result for patients with a result needing molecular confirmation on a 4th generation HIV testing algorithm (Abbott Architect, Multispot/Geenius confirmatory test) was stratified based on the patient's white blood cell (WBC) count and the magnitude of Architect result Signal Cut Off ratio (S/CO).

RESULTS

A total of 61,666 patients were tested with 658 (1.1%) positive results and 76 (0.12%) patients needing molecular confirmation. Patients with an S/CO of <5 or an S/CO of 5-100 with a WBC > 6.5 × 10 ⁹ cells/l had a significantly lower risk of a positive molecular HIV test (0/48, 0%) than patients with an S/CO 5-100 with a WBC < 6.0 s × 10 ⁹ cells/l (5/9, 56%, p < .001) or an S/CO > 100 (2/2, 100%, p < .001). Pregnant women had a significantly lower rate of positive test results (24/6924, 0.4%) than non-pregnant patients (634/54742, 1.1%, p < 0.001). All 12 cases needing molecular confirmation in pregnant women had negative NAT test results.

CONCLUSIONS

Patients who need their HIV results confirmed with molecular testing using a 4^th generation algorithm that includes the Abbott Architect System can be further stratified into low, intermediate, and high risk groups based on additional laboratory information pending the results of molecular testing. This risk stratification may be of value for patient counseling and treatment of women in labor.

Improving Discrete Data Capture in Synoptic Reports With Optional Free-Text Modifiers

PURPOSE

Upfront, discrete data capture in synoptic reporting fails when pathologists choose a response not associated with discrete data. We sought to determine the factors associated with this event.

METHODS

The results of all "Other" entries in four common tumor sites in synoptic reports were reviewed.

RESULTS

"Other" entries occurred in 329 of 13,421 questions (2.5%). In 306 of these 329 questions (93.0%), the pathologist appeared to choose this response because they wished to add additional information to an already existing response that was associated with discrete data capture. As a result, the addition of a free-text modifiers to existing responses would allow pathologist to add this additional information while still selecting a response associated with discrete data capture, significantly improving the total discrete data capture (13,092 of 13,421 questions [97.5%] v 13,398 of 13,421 questions [99.8%]; P < .001).

CONCLUSION

The addition of free-text modifiers to structured responses in synoptic reports could significantly improve the discrete data capture rate.

Time to Prostate-specific Antigen Nadir and the Risk of Death From Prostate Cancer Following Radiation and Androgen Deprivation Therapy

OBJECTIVE

To assess whether the time to prostate-specific antigen (PSA) nadir (TTN) has differential prognostic value in men who reach an undetectable vs detectable PSA nadir.

METHODS

Two hundred and four men from a prospective randomized controlled trial involving radiation therapy with or without 6 months of androgen deprivation therapy in unfavorable risk Prostate cancer (CaP) at academic or community based centers in Massachusetts, enrolled between 1995 and 2001. Adjusted hazard ratios (AHR) of the risk of CaP-specific mortality calculated using Fine and Gray competing risk regression.

RESULTS

After a median follow-up of 18.17years, 160 men died; 30 (18.75%) of CaP. Among men with a PSA nadir ≥ 0.2ng/ml, a TTN < median (12 months) was significantly associated with an increased CaP-specific mortality-risk vs the median or more (AHR 5.07, 95% CI 2.10-12.23, P <.001); whereas this association was not observed among men with a PSA nadir of < 0.2ng/mL, (AHR 9.9, 95% CI 0.23-433.8, P = .23).

CONCLUSION

Men with both a short TTN and detectable PSA nadir could be considered for entry on randomized controlled trials at a novel entry point prior to PSA failure at the time of PSA nadir to completeplanned conventional androgen deprivation therapy vs that plus agent(s) shown to improve outcomes in men with or at high risk of having castrate-resistant CaP.

Freeing the data from cytology databases in order to improve the quality of cytology

INTRODUCTION

To review how changes in data storage and analysis can impact quality and quality assessment in cytology.

METHODS

Review of the literature.

RESULTS

All quality assessment is dependent on the data available for review and the methods available for evaluation. Current laboratory information systems (LISs) incorporate both a relational or hierarchical database and built in methods to analyze current quality assessment standards. In contrast, most information systems outside of medicine are separating data storage from analysis, allowing increasingly more sophisticated forms of evaluation.

CONCLUSION

There is an opportunity for improvement in cytology by improving the way data can be extracted and analyzed from the cytology LIS.

Thyroid FNA biopsies comprised of abundant, mature squamous cells can be reported as benign: A cytologic study of 18 patients with clinical correlation

BACKGROUND

A thyroid nodule comprised almost exclusively of mature, benign-appearing squamous cells is an uncommon finding in fine-needle aspiration (FNA) biopsies of thyroid nodules. Reporting such specimens was not originally addressed by The Bethesda System for Reporting Thyroid Cytopathology. The authors correlated the biologic behavior of the specimens with their benign cytologic appearance through clinical, radiographic, and surgical follow-up.

METHODS

The pathology archives of 3 tertiary hospitals were searched for thyroid FNA specimens consisting of mature squamous cells without atypia. The authors reviewed all available slides and included only cases that were moderately to highly cellular; nucleated or anucleate squamous cells without atypia comprised the vast majority of the cellularity. Available clinical information and/or thyroid ultrasound examination(s) were reviewed by an endocrinologist or radiologist, respectively.

RESULTS

A total of 18 patients (7 men and 11 women; age range, 19-76 years) with 20 nodules met the prespecified inclusion criteria. The average nodule size was 2.1 cm. Common sonographic characteristics included a well-defined appearance, the lack of internal vascularity, a thin outer wall, general hypoechogenicity with low-intermediate internal echoes, and posterior acoustic enhancement. Clinical and radiographic follow-up (mean, 3.8 years; range, <1 to 9 years) was available for 9 patients, and all nodules were stable. All 4 cases with histologic follow-up were benign squamous-lined cysts.

CONCLUSIONS

The findings of the current study suggest that thyroid FNA specimens comprised almost exclusively of mature squamous cells can be reported as benign. Cancer Cytopathol 2018;126:336-41. © 2018 American Cancer Society.

Fine-needle aspiration of tubulocystic renal cell carcinoma

We report two cases of tubulocystic renal cell carcinoma, a rare renal tumor the cytology of which has not been previously reported. Both aspirates were cellular and contained large sheets of cells with abundant granular cytoplasm, distinct cell borders and intracellular windows, distinct to prominent nucleoli, rare intracytoplasmic vacuoles, and rare nuclear grooves. Cells with variable amounts of cytoplasm were also arranged in small groups, some of which resembled spherules. The large sheets of cells with windows appeared specific for tubulocystic carcinoma; the spherules could easily be confused with a papillary renal cell carcinoma.

Low testosterone at first PSA failure and assessment of the risk of death in men with unfavorable-risk prostate cancer treated on prospective clinical trials

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Background: Low testosterone at prostate cancer diagnosis has been associated with a worse prognosis. Whether this is true and how to define the best treatment approach at first PSA failure following definitive therapy and prior to the documentation of metastatic disease has not been elucidated and was studied. Methods: Between 1995 to 2001, 58 men with unfavorable-risk prostate cancer treated on clinical trials with radiation and androgen deprivation therapy (ADT) had testosterone levels at PSA failure available. Cox and Fine and Gray regressions were performed to ascertain whether low versus normal testosterone at PSA failure was associated with the risk of prostate cancer-specific, other-cause and all-cause mortality (PCSM, OCM, ACM) adjusting for age, salvage ADT use and known prostate cancer prognostic factors. Results: After a median follow-up of 6.68 years following first PSA failure, 31 men (53.4%) died; 10 from prostate cancer (32.3%), of which 8/11 (72.7%) versus 2/47 (4.3%) occurred in men with low versus normal testosterone at PSA failure, respectively. A significant increase in the risk of ACM (adjusted hazard ratio, AHR [2.54, 95% CI 1.04-6.21]; P = 0.04) and PCSM (AHR [13.71, 95% CI 2.4-78.16]; P = 0.003), with a reciprocal trend toward decreased risk of OCM (AHR [0.18, 95% CI 0.02-1.55]; P = 0.12) was observed in men with low versus normal testosterone at first PSA failure. Conclusions: Low testosterone at first PSA failure confers a very poor prognosis. Given prolonged survival when abiraterone or docetaxel is added to ADT in men with castrate-sensitive metastatic prostate cancer and possibly in men with localized high-risk prostate cancer provides rationale to support their use with ADT in men with low testosterone at PSA failure in the setting of a phase II trial.

Early versus delayed initiation of salvage androgen deprivation therapy and the risk of prostate cancer-specific mortality

189

Background: We sought to ascertain whether there is an association between prostate cancer (PC)-specific mortality (PCSM) and salvage androgen deprivation therapy (ADT) timing amongst men with short versus long prostate-specific antigen doubling times (PSA-DT)s. Methods: The study cohort was selected from 206 men with localized unfavorable-risk PC who were randomized to radiation therapy (RT) or RT plus 6 months of ADT between 1995 and 2001. Fifty-four men who received salvage ADT for PSA failure after a median follow up of 18.72 years following randomization defined the study cohort. Fine-Gray competing risks regression analyzed whether the timing of salvage ADT was associated with an increased risk of PCSM after adjusting for age, comorbidity, known PC prognostic factors, and previously identified interactions. Results: After a median follow-up of 5.68 years (IQR 3.05 - 9.56) following salvage ADT 49 of the 54 men (91%) died, 27 from PC (54% of deaths). Increasing PSA-DT as a continuous covariate was associated with a decreasing risk of PCSM (adjusted hazard ratio [AHR] 0.33, 95% CI 0.13, 0.82; P=0.02). Amongst men with a long PSA-DT (≥6 months), initiating salvage ADT later (PSA>12ng/mL, upper quartile) versus earlier was associated with an increased risk of PCSM (AHR 8.84, 95% CI 1.99-39.27; P=0.004); whereas for men with a short (<6 months) PSA-DT (AHR 1.16, 95% CI 0.38-3.54; P=0.79) this was not true. Conclusions: Early initiation of salvage ADT for post-RT PSA recurrence in men with a PSA-DT of 6 months or more may reduce the risk of PCSM, arguing against the unproven assumption that patients with a short PSA-DT are those most likely to benefit from early initiation of salvage ADT. Clinical trial information: NCT00116220.

Impact of time to testosterone rebound and comorbidity on the risk of cause-specific mortality in men with unfavorable-risk prostate cancer

BACKGROUND

Herein, the authors evaluated how the time to testosterone rebound (TTR) after radiotherapy (RT) and 6 months of androgen deprivation therapy (ADT) impacted the risk of prostate cancer-specific mortality (PCSM) and cardiovascular-specific mortality (CVM) among men with varying comorbidity extent.

METHODS

Between 1995 and 2001, a total of 206 men who were randomized to receive RT either alone or with 6 months of ADT for unfavorable-risk PC and who had a comorbidity score assigned using the Adult Comorbidity Evaluation 27 metric comprised the study cohort. Multivariable competing risk regression was used to evaluate the impact of and possible interaction between comorbidity and TTR on PCSM and CVM.

RESULTS

After a median follow-up of 18.19 years, 30 men (18.6%), 39 men (24.2%), and 92 men (57.1%), respectively, had died of PC, CV disease, or other causes. As TTR increased, PCSM significantly decreased in men with no or minimal (adjusted hazard ratio [AHR], 0.53, 95% confidence interval [95% CI], 0.34-0.84 [P =.007]) and moderate to severe (AHR, 0.37; 95% CI, 0.14-0.99 [P = .048]) comorbidity. However, increasing TTR significantly increased the risk of CVM among men with moderate to severe comorbidity (AHR, 1.87; 95% CI, 1.40-2.49 [P <.001]), but not those with no or minimal comorbidity (AHR, 0.86; 95% CI, 0.57-1.29 [P =.46]), leading to a significant interaction between TTR and comorbidity (P = .001).

CONCLUSIONS

The results of the current study indicate that considering an intermittent course of ADT such that the TTR approaches 18 months, instead of continuous long-term administration of ADT, in men with moderate to severe comorbidity and high-risk PC may reduce the increased risk of CVM without increasing the risk of PCSM. Cancer 2018;124:1391-9. © 2018 American Cancer Society.

Low testosterone at first prostate-specific antigen failure and assessment of risk of death in men with unfavorable-risk prostate cancer treated on prospective clinical trials

BACKGROUND

Low testosterone at the time of diagnosis of prostate cancer has been associated with a worse prognosis. Whether this is true and how to define the best treatment approach at the time of first prostate-specific antigen (PSA) failure to the authors' knowledge has not been elucidated to date and was studied herein.

METHODS

Between 1995 and 2001, a total of 58 men with unfavorable-risk PC who were treated on clinical trials with radiotherapy and androgen deprivation therapy (ADT) had available testosterone levels at the time of PSA failure. Cox and Fine and Gray regressions were performed to ascertain whether low versus normal testosterone was associated with the risk of PC-specific mortality, other-cause mortality, and all-cause mortality adjusting for age, salvage ADT, and known PC prognostic factors.

RESULTS

After a median follow-up of 6.68 years after PSA failure, 31 men (53.4%) had died; 10 of PC (32.3%), of which 8 of 11 (72.7%) versus 2 of 47 (4.3%) deaths occurred in men with low versus normal testosterone at the time of PSA failure, respectively. A significant increase in the risk of all-cause mortality (adjusted hazard ratio [AHR], 2.54; 95% confidence interval [95% CI], 1.04-6.21 [P = .04]) and PC-specific mortality (AHR, 13.71; 95% CI, 2.4-78.16 [P = .003]), with a reciprocal trend toward a decreased risk of other-cause mortality (AHR, 0.18; 95% CI, 0.02-1.55 [P = .12]) was observed in men with low versus normal testosterone.

CONCLUSIONS

Low, but not necessarily castrate, testosterone levels at the time of PSA failure confer a very poor prognosis. These observations provide evidence to support testosterone testing at the time of PSA failure. Given prolonged survival when abiraterone or docetaxel is added to ADT in men with castrate-sensitive metastatic PC and possibly localized high-risk PC provides a rationale supporting their use with ADT in men with low testosterone in the setting of a phase 2 trial. Cancer 2018;124:1383-90. © 2017 American Cancer Society.