The extent of biopsy involvement as an independent predictor of extraprostatic extension and surgical margin status in low risk prostate cancer: implications for treatment selection

PURPOSE: We identify predictors of extraprostatic extension and positive surgical margins in patients with low risk prostate cancer (prostate specific antigen [PSA] 10 ng./ml. or less, biopsy Gleason score 7 or less and clinical stage T1c-2b). MATERIALS AND METHODS: From August 1997 to January 1999, 143 previously untreated patients underwent radical retropubic prostatectomy for clinically localized prostate cancer. A total of 62 patients were low risk, with PSA 10 ng./ml. or less, biopsy Gleason score 7 or less and clinical stage T1c-2b, and had sextant biopsy with separate pathological evaluation of each sextant cores. PSA, clinical stage, biopsy Gleason score, average percentage of cancer in the entire biopsy specimen, maximum percentage of cancer on the most involved core, number of cores involved and bilaterality were evaluated for association with extraprostatic extension, seminal vesicle involvement and positive surgical margins. RESULTS: Of the 62 patients 13 (21%) had extraprostatic extension, 6 (10%) seminal vesicle involvement and 20 (32%) positive surgical margins. Average percentage greater than 10% and maximum percentage greater than 25% were associated with extraprostatic extension (p = 0.01 and 0.004, respectively). Average percentage greater than 10%, maximum percentage greater than 25%, more than 2 cores involved and bilaterality were associated with positive surgical margins (p = 0.007, 0.01, 0.002 and 0.03, respectively). On multivariate analysis maximum percentage remained the only independent predictor of extraprostatic extension (p = 0.03), and the number of cores involved remained an independent predictor of positive surgical margins (p = 0.01). Biopsy Gleason score, PSA and clinical stage did not correlate with extraprostatic extension or positive surgical margins in this patient population. CONCLUSIONS: In low risk prostate cancer the extent of biopsy involvement significantly correlates with the risk of extraprostatic extension and positive surgical margins. Biopsy information should be considered when selecting and modifying treatment modalities.     

Testosterone and high‐sensitive C‐reactive protein in coronary artery disease patients awaiting coronary artery bypass graft

Natural androgens inhibit atherosclerosis in men. This study aimed to examine whether testosterone and high‐sensitive C‐reactive protein differ between patients with coronary artery disease and those without coronary artery disease and to determine the association with the severity of coronary artery disease. Two hundred and six male subjects were recruited. Serum total testosterone and high‐sensitive C‐reactive protein were estimated. Severity of coronary artery disease was assessed by angiographic scores. Total testosterone level in patients was significantly different from controls (11.4 ± 2.7 vs. 18.1 ± 7.2 nm P = 0.001) and high‐sensitive protein level in cases was significantly higher compared to controls (3.37 ± 1.62 mg l^?1 vs. 1.71 ± 0.60 mg l^?1, P = 0.001). Testosterone levels were not significantly different with vessel (P = 0.592), Leaman (P = 0.694) and Gensini (P = 0.329) score groups, but high‐sensitive C‐reactive protein showed significant positive correlation among the respective groups (P = 0.005, P = 0.028, P = 0.015). Testosterone was lower, while high‐sensitive C‐reactive protein was higher in patients compared to controls. Testosterone showed no correlation with the severity of atherosclerosis, but high‐sensitive C‐reactive protein showed significant positive correlation.     

Multiple once-daily subcutaneous doses of pasireotide were well tolerated in healthy male volunteers: a randomized, double-blind, placebo-controlled, cross-over, Phase I study

A randomized, double-blind, placebo-controlled, cross-over, dose-escalating, single-center study was conducted to evaluate the safety, tolerability, and pharmacokinetic (PK) profile of multiple once-daily (qd) subcutaneous (sc) doses of pasireotide in healthy male subjects. Subjects received pasireotide 50, 200, or 600?μg?sc?qd for 14?days and placebo in separate sequences. Thirty-three subjects were randomized. The most frequently reported drug-related adverse events were injection-site reactions (n?=?18), diarrhea (n?=?14) and nausea (n?=?10), which were mostly mild or moderate in intensity. Pasireotide 600?μg?sc was associated with pre- and post-prandial elevations in glucose levels relative to placebo; however, this effect was less pronounced on day 14 compared with day 1. PK steady state appeared to be achieved after 3?days of dosing and PK exposures had a moderate accumulation of 20-40?% across doses. Pasireotide demonstrated fast absorption (T (max,ss): 0.25-0.5?h), low clearance (CL/F (ss): 8.10-9.03?L/h), long effective half-life (T (?,eff): ~12?h, on average between 9.7 and 13.1?h for 50, 200, and 600?μg?sc?qd), and large volume of distribution (V (z)/F (ss): 251-1,091?L) at steady state. Dose proportionality was confirmed for C (max,ss); other PK parameters (C (max), AUC(0-24?h) and AUC(tau)) were approximately dose proportional. Growth hormone inhibition was observed with pasireotide 200 and 600?μg?sc?qd. Gallbladder volume increased post-prandially with pasireotide 200 and 600?μg?sc?qd, which appeared to correlate with reduced levels of cholecystokinin at these doses. Pasireotide was generally well tolerated up to the tested dose of 600?μg?qd, with a linear and time-independent PK profile after sc qd dosing in healthy subjects.     

Undiagnosed Acute Viral Febrile Illnesses,Sierra Leone

Sierra Leone in West Africa is in a Lassa fever–hyperendemic region that also includes Guinea and Liberia. Each year, suspected Lassa fever cases result in submission of ≈500–700 samples to the Kenema Government Hospital Lassa Diagnostic Laboratory in eastern Sierra Leone. Generally only 30%–40% of samples tested are positive for Lassa virus (LASV) antigen and/or LASV-specific IgM; thus, 60%–70% of these patients have acute diseases of unknown origin. To investigate what other arthropod-borne and hemorrhagic fever viral diseases might cause serious illness in this region and mimic Lassa fever, we tested patient serum samples that were negative for malaria parasites and LASV. Using IgM-capture ELISAs, we evaluated samples for antibodies to arthropod-borne and other hemorrhagic fever viruses. Approximately 25% of LASV-negative patients had IgM to dengue, West Nile, yellow fever, Rift Valley fever, chikungunya, Ebola, and Marburg viruses but not to Crimean-Congo hemorrhagic fever virus.     

Gossypiboma Presenting as Coloduodenal Fistula – Report of a Rare Case With Review of Literature

The term gossypiboma is used to describe a mass of cotton matrix left behind in a body cavity intraoperatively. The most common site reported is the abdominal cavity. It can present with abscess, intestinal obstruction, malabsorption, gastrointestinal hemorrhage, and fistulas. A 37-year-old woman presented with pain in the right hypochondrium for 2 months following open cholecystectomy. As she did not improve with proton pump inhibitors, an esophagogastroduodenoscopy (EGD) was done, which showed a possible gauze piece stained with bile in the first part of the duodenum. Contrast-enhanced computed tomography (CECT) of the abdomen revealed an abnormal fistulous communication of the first part of duodenum with proximal transverse colon, with a hypodense, mottled lesion within the lumen of the proximal transverse colon plugging the fistula, suggestive of a gossypiboma. Excision of the coloduodenal fistula, primary duodenal repair, and feeding jejunostomy was done. The patient recovered well and is now tolerating normal diet. Coloduodenal fistula is usually caused by Crohn''s disease, malignancy, right-sided diverticulitis, and gall stone disease. Isolated coloduodenal fistula due to gossypiboma has not been reported in the literature so far to the best of our knowledge. We report this case of coloduodenal fistula secondary to gossypiboma for its rarity and diagnostic challenge.Key words: Surgical sponges, Intestinal fistula, Multidetector computed tomographyThe first report of a coloduodenal fistula was by Haldane in 1862, and it was malignant from the hepatic flexure.¹ Coloduodenal fistula is caused by Crohn''s disease, malignancy, right-sided diverticulitis, and gall stone disease, but isolated coloduodenal fistula due to gossypiboma has not been reported in the literature to the best of our knowledge. Gossypiboma is known to present as intra-abdominal abscess, intestinal obstruction, and fistulization, but coloduodenal fistula has not been reported as a mode of presentation. We report this case of coloduodenal fistula secondary to gossypiboma for its rarity and diagnostic challenge.     

Metachronous Multiple Primary Malignant Neoplasms of the Stomach and the Breast: Report of Two Cases With Review of Literature

Multiple primary malignant neoplasm is the occurrence of a second primary malignancy in the same patient within 6 months of the detection of first primary (synchronous), or 6 months or more after primary detection (metachronous). Multiple primary malignant neoplasms are not very frequently encountered in clinical practice. The relative risk for a second primary malignancy increases by 1.111-fold every month from the detection of the first primary malignancy in any individual. We present 2 patients treated for carcinoma of the breast who developed a metachronous primary malignancy in the stomach to highlight the rare occurrence of multiple primary malignant neoplasms. These tumors were histologically dissimilar, with distinct immunohistochemical parameters. The importance lies in carefully identifying the second primary malignancies, not dismissing them as metastases, and treating them accordingly.Key words: Breast neoplasms, Stomach neoplasms, Neoplasms, Second primaryBreast cancer is the most common malignancy among women worldwide. With proper screening, earlier detection, and improved treatment, survival has greatly increased, with the result that there is now a large population of women with a present or past history of breast cancer. This has led to an increased detection of second primary malignancies among these women. The relative risk for a second primary malignancy increases by 1.111-fold every month from the detection of the first primary malignancy in any individual.¹ Several authors have reported on a lesion in the stomach being labeled as a second primary malignancy and subsequently found to be metastasis. When the primary breast tumor is positive for estrogen and progesterone receptors (ER/PRs) and the stomach tumor is ER/PR negative, the diagnosis is established easily.² However, studies have shown that some primary gastric cancers can have ER/PR positivity. Further, if the primary breast lesion is ER/PR negative, the same cannot be used as a marker. Here, we present 2 breast cancer patients who developed second primary malignancies in the stomach and the final diagnosis was established based on histopathology and immunohistochemistry.     

Giant Inguinoscrotal Hernia—Report of a Rare Case With Literature Review

Massive inguinoscrotal hernias extending below the midpoint of the inner thigh, in the standing position constitute giant inguinoscrotal hernias. We report a patient who presented with giant right inguinal hernia with bilateral hydrocele for 25 years. He had no cardiorespiratory illnesses. He was taken up for surgery under general anesthesia after preoperative respiratory exercises. Sliding hernia with entire greater omentum, small bowel, and appendix as contents was identified. Meshplasty after omentectomy with bilateral subtotal excision of sac, right orchidectomy, and scrotoplasty were done. Giant inguinoscrotal hernias pose significant problems while replacing bowel contents because of the increase in intraabdominal and intrathoracic pressures. Recurrence is another complication seen after successful surgical management. Various techniques such as preoperative pneumoperitoneum, debulking abdominal contents with extensive bowel resections, or omentectomy and phrenectomy have been tried. Postoperative elective ventilation is also needed in many cases. We describe simple reduction with omentectomy as a viable technique in this patient. He did not need elective ventilation due to preoperative respiratory exercises and preparation and review of the literature.Key words: Debulking, Giant inguinoscrotal hernia, Massive inguinoscrotal hernia, Phrenectomy, VentilationGiant inguinoscrotal hernias are defined as those extending below the midpoint of the inner thigh, in the standing position.¹ These hernias are rare and usually the result of neglect or fear of surgical procedures and are prevalent in the rural population.² These massive hernias pose significant problems resulting from cardiorespiratory compromise following sudden increase in intra-abdominal pressure during replacement of herniated viscera.³ In order to circumvent these complications, techniques such as debulking, phrenectomy, and progressive pneumoperitoneum have been described.³ Here, we present a patient with giant inguinoscrotal hernia where simple reduction with omentectomy was successful, and we review the literature.