Prostate cancer: the new evidence base for diagnosis and treatment

Although prostate cancer (PC) has a significant mortality, there is debate regarding the utility of PC screening. This debate continues as major studies investigating the value of population-based screening have yet to be concluded. Despite this, there is increasing evidence from preliminary reports from these series, as well as numerous others relating to outcome prediction for PC, that early detection leads to improved outcomes and a decrease in the burden of metastatic disease on our healthcare system. PC is rarely symptomatic until it has metastasised to bone and because of this PSA-based screening remains the only widely available and reliable method of diagnosis for organ-confined disease. There is now compelling evidence to show that: 1. Cancers diagnosed by screening are more likely to be early stage, when most can be cured by a number of different treatment options. 2. The maximum benefits of screening are for men aged 50-70 years. Older men have a greater chance of a clinically insignificant cancer being diagnosed for which treatment is not necessary. 3. The familial risks of PC are well recognised. In particular, men with one or more first-degree relatives already diagnosed with the disease should be actively encouraged to undergo screening. 4. Modern histopathological assessment of fine core needle biopsies of the prostate allows for the likely behaviour of cancer present to be accurately predicted. Changes that mimic those of malignancy can be confidently identified, so these cases are no longer incorrectly diagnosed. These improvements mean that now most men aged 50-70 years diagnosed with PC will have clinically significant cancers that require treatment.     

Complex phenotypes in the haemoglobinopathies: recommendations on screening and DNA testing

This document considers a number of scenarios involving complex haemoglobinopathies and provides 28 recommendations at both the clinical and laboratory levels on how these should be managed.     

Broadsheet. Number 50: Diagnosis of human cytomegalovirus infection and disease.

Human cytomegalovirus (CMV) remains an important cause of illness in immunocompromised individuals and the most common viral cause of congenital malformation. The tests available for diagnosis of CMV include serology, antigen detection, virus culture, tissue histopathology and nucleic acid detection. The diagnosis of CMV remains difficult because of the issues of virus latency, virus infection versus clinical disease and virus reactivation. The tests available and the use of these tests are undergoing significant changes. This Broadsheet presents a review of these tests, particularly in the diagnosis of congenital infection and infection in pregnant women and immunocompromised individuals.     

Mis-identification of factor inhibitors by diagnostic haemostasis laboratories: recognition of pitfalls and elucidation of strategies. A follow up to a large multicentre evaluation

AIMS: We previously reported the ability of diagnostic haemostasis facilities to identify coagulation factor abnormalities and inhibitors, through a large multi-centre study conducted on behalf of the Royal College of Pathologists of Australasia (RCPA) Quality Assurance Program (QAP). In the current report, additional data evaluation aims to (1) help identify the reasons behind the failures in inhibitor identification, (2) highlight the pitfalls in inhibitor testing, and (3) help elucidate some strategies for overcoming these problems and to assist in better identification and characterisation of inhibitors. METHODS: Forty-two laboratories blind tested a set of eight samples for the presence or absence of inhibitors. These included true factor inhibitors (FVIII and FV), and other samples that reflected potential pre-analytical variables (e.g., heparin contamination, serum, EDTA plasma, aged plasma) that might arise and complicate inhibitor detection or lead to false inhibitor identification. RESULTS: There was a wide scatter of inhibitor results, with false positive and false negative inhibitor identification, and mis-identification of inhibitors (e.g., FVIII inhibitor identified where FV inhibitor present). Further analysis of the pattern of reported laboratory results, including routine coagulation testing and factor profiles, allowed some additional interpretative power to provide strategies that will assist laboratories to improve the accuracy of inhibitor identification in the future. CONCLUSIONS: There are currently occasional lapses in factor inhibitor identification, which this report will hopefully help address.     

Protein expression levels of carcinoembryonic antigen (CEA) in Danish ovarian cancer patients: from the Danish 'MALOVA'ovarian cancer study

AIMS: To determine the variation in expression of carcinoembryonic antigen (CEA) in 760 epithelial ovarian tumours from Denmark, and to correlate expression with clinicopathological parameters and prognosis for the disease. METHODS: Using tissue arrays (TA), we analysed CEA expression in tissues from 189 women diagnosed with low malignant potential ovarian tumours (LMP, borderline ovarian tumours) and 571 women diagnosed with ovarian cancer (OC). RESULTS: Using 30% as the cut-off level for CEA over-expression, 18% of LMPs and 4% of OCs were positive. A higher proportion of mucinous tumours were positive compared with other histological subtypes (p<0.00001). A univariate survival analysis suggested a shorter disease specific survival for patients with 30% or higher CEA expression in the tumour tissue (p = 0.004). In a Cox survival analysis, which included 569 OC cases subgrouped by stage (I to IV), the highest CEA expression compared with no expression was found to be a prognostic factor (level 3 versus negative: HR = 2.12, 95%CI 1.11-4.05). FIGO stage, residual tumour after primary surgery, age at diagnosis, other histological types versus serous adenocarcinoma and low versus high histological grade tumours were also prognostic factors. CONCLUSION: These data suggest that CEA expression is an independent prognostic factor for mucinous OC in Danish patients.     

Mutations in rpoB gene and rifabutin susceptibility of multidrug-resistant Mycobacterium tuberculosis strains isolated in Australia.

Control of tuberculosis, the single largest killer among the infectious diseases, has been threatened by the emergence of multidrug-resistant Mycobacterium tuberculosis (MDRTB) infection due to the limited treatment options. Rifampicin (RIF) resistance is considered as a marker for MDRTB. The aim of this study was the detection of rpoB gene mutations and rifabutin resistance in MDRTB strains recently isolated in Australia by a line probe assay (INNO-LiPA Rif. TB, Innogenetics). Rifabutin and RIF susceptibility of 20 MDRTB and 16 RIF-sensitive M. tuberculosis complex clinical isolates were studied. The overall concordance of the line probe assay (LiPA) with phenotypic RIF susceptibility test was 96%. Seven distinct nucleotide substitutions were identified in 21 of 22 RIF-resistant isolates of diverse geographical origins, but in none of the RIF-sensitive strains. The majority (71%) of mutations occurred in the 526-533 codons and were associated with resistance to rifabutin and RIF. Of the RIF-resistant MDRTB strains, 18% appeared to be rifabutin-sensitive and produced delta S2 and delta S3 INNO-LiPA patterns. We conclude that amino acid substitutions at Asp516 and Ser522 in the rpoB gene in RIF-resistant M. tuberculosis predict rifabutin susceptibility for MDRTB. Use of the LiPA for RIF and rifabutin resistance may facilitate the rapid response required to limit the extent and severity of MDRTB transmission and infection.