Ruling out clinically significant prostate cancer with negative multi-parametric MRI

Purpose

To evaluate the negative predictive value (NPV) of a negative prostate multi-parametric magnetic resonance imaging (mpMRI) in ruling out clinically significant prostate upon 12-core systematic biopsy.

Methods

We retrospectively reviewed 114 men evaluated at our institution who underwent systematic 12-core biopsy within 1 year of a negative prostate mpMRI. Clinicopathologic features were evaluated and NPV was calculated for detection of clinically significant (Gleason ≥ 7) cancer. Regression analysis was performed to identify clinical predictors of biopsy outcome.

Results

Overall, 88 (77.2%) patients in our cohort had no cancer detected upon biopsy. The highest pathologic grade was Gleason 6 (3 + 3) in 22 (19.3%) patients, and Gleason ≥ 7 in 4 (3.6%) patients. NPV for detecting Gleason ≥ 7 cancer was 96.5% (95% CI 93.1–99.9%) in the entire negative MRI cohort, 100% in those who were prostate biopsy naïve (n = 20), 100% in those with a prior negative biopsy (n = 53), and 90% in those who have had a previous positive biopsy and on active surveillance (n = 41). Regression analysis identified no predictors of significant cancer in our cohort.

Conclusion

In our cohort of men with no lesions detected on prostate mpMRI, we found very low rates of clinically significant cancer on systematic 12-core biopsy. In the few patients who diagnosed with prostate cancer, the majority had low-risk disease and could remain on active surveillance. Although validation studies and greater sample size is needed before clinical recommendations can be made, our data suggest patients with negative mpMRI evaluated by experienced radiologists may avoid unnecessary prostate biopsy and potential overtreatment.

     

Laparoscopic approach to ovarian pathology in children and adolescents

Laparoscopic procedures are constantly finding wider application in general and pediatric surgery. The female child and adolescent presenting with suspected acute or chronic ovarian pathology may be an ideal candidate for laparoscopic surgery. From March 1992 to December 1993, six girls aged 7 to 18 years underwent seven laparoscopic operations for ovarian pathology at Childrens Hospital Los Angeles. Clinical presentations included virilization with primary amenorrhea (1), precocious puberty (1), malignant dysgerminoma (second look) (1), and abdominal pain (3). Postoperative diagnoses were dysgerminoma (1), bilateral gonadoblastoma in a 46 XY chromosomal phenotypic femal with dysgenetic gonads (1), negative bipsy (1), serous cystadenoma with acute torsion (1), ovarian cysts (1), and ovarian torsion (1). Operations performed were unilateral salpingo-oophorectomy (1), unilateral salpingo-oophorectomy with contralateral biopsy (2), bilateral salpingo-oophorectomy (1), diagnostic biopsy (2), and ovarian cystectomy with oophoropexy (1). There were no operative complications. One patient underwent two operations, a biopsy followed by unilateral salpingo-oophorectomy. Only one patient required a mini-laparotomy for delivering a large tumor mass. Mean operative time was 138 min, mean hospital stay 2.0 days. We encountered two malignant cases, which were definitively treated by laparoscopic resection. These two patients remained free of disease 12 to 18 months later. The laparoscopic approach to ovarian pathology in children and adoloscents in an effective method for diagnosis as well as definitive therapy. Our initial experience is presented followed by recommendations for clinical practice.     

Areas of brain activation in males and females during viewing of erotic film excerpts

Various lines of evidence indicate that men generally experience greater sexual arousal (SA) to erotic stimuli than women. Yet, little is known regarding the neurobiological processes underlying such a gender difference. To investigate this issue, functional magnetic resonance imaging was used to compare the neural correlates of SA in 20 male and 20 female subjects. Brain activity was measured while male and female subjects were viewing erotic film excerpts. Results showed that the level of perceived SA was significantly higher in male than in female subjects. When compared to viewing emotionally neutral film excerpts, viewing erotic film excerpts was associated, for both genders, with bilateral blood oxygen level dependent (BOLD) signal increases in the anterior cingulate, medial prefrontal, orbitofrontal, insular, and occipitotemporal cortices, as well as in the amygdala and the ventral striatum. Only for the group of male subjects was there evidence of a significant activation of the thalamus and hypothalamus, a sexually dimorphic area of the brain known to play a pivotal role in physiological arousal and sexual behavior. When directly compared between genders, hypothalamic activation was found to be significantly greater in male subjects. Furthermore, for male subjects only, the magnitude of hypothalamic activation was positively correlated with reported levels of SA. These findings reveal the existence of similarities and dissimilarities in the way the brain of both genders responds to erotic stimuli. They further suggest that the greater SA generally experienced by men, when viewing erotica, may be related to the functional gender difference found here with respect to the hypothalamus.     

Surgical treatment of pancreatic cholera: a case report

After surgical resection for rectosigmoid carcinoma a 63-year-old man had secretory diarrhea causing severe metabolic acidosis, hypokalemia, hypercalcemia and dehydration. Subsequent investigations revealed a mass measuring 4 × 5 cm in the uncinate process of the pancreas and an elevated vasoactive intestinal polypeptide concentration. The diarrhea responded to treatment with the somatostatin analogue, Sandostatin, and remained under control during a prolonged preoperative period. The patient underwent a Whipple procedure with immediate lessening of his diarrhea. This report illustrates a classic case of vipoma and demonstrates the need to consider this condition in the differential diagnosis of secretory diarrhea, even in the presence of other gastrointestinal lesions. The effectiveness of somatostatin analogues in stabilizing the diarrhea preoperatively is also well illustrated.