Postoperative nomogram predicting the 10-year probability of prostate cancer recurrence after radical prostatectomy.

PURPOSE: A postoperative nomogram for prostate cancer recurrence after radical prostatectomy (RP) has been independently validated as accurate and discriminating. We have updated the nomogram by extending the predictions to 10 years after RP and have enabled the nomogram predictions to be adjusted for the disease-free interval that a patient has maintained after RP. METHODS: Cox regression analysis was used to model the clinical information for 1,881 patients who underwent RP for clinically-localized prostate cancer by two high-volume surgeons. The model was externally validated separately on two independent cohorts of 1,782 patients and 1,357 patients, respectively. Disease progression was defined as a rising prostate-specific antigen (PSA) level, clinical progression, radiotherapy more than 12 months postoperatively, or initiation of systemic therapy. RESULTS: The 10-year progression-free probability for the modeling set was 79% (95% CI, 75% to 82%). Significant variables in the multivariable model included PSA (P = .002), primary (P < .0001) and secondary Gleason grade (P = .0006), extracapsular extension (P < .0001), positive surgical margins (P = .028), seminal vesicle invasion (P < .0001), lymph node involvement (P = .030), treatment year (P = .008), and adjuvant radiotherapy (P = .046). The concordance index of the nomogram when applied to the independent validation sets was 0.81 and 0.79. CONCLUSION: We have developed and validated as a robust predictive model an enhanced postoperative nomogram for prostate cancer recurrence after RP. Unique to predictive models, the nomogram predictions can be adjusted for the disease-free interval that a patient has achieved after RP.     

Late follow-up (41 to 102 months) of medically treated patients with coronary artery spasm and minor atherosclerotic coronary obstructions

From a series of 37 patients with coronary artery spasm and less than 70% diameter narrowing treated initially with verapamil and nitrates, 33 were followed up 41 to 102 months (mean 62). One patient died from carcinoma of the lung and 3 could not be traced. Before diagnosis, 3 had nontransmural myocardial infarction and 10 had either ventricular tachycardia and fibrillation or atrioventricular block. During follow-up there were no cardiac deaths or myocardial infarctions. Asymptomatic periods of more than 3 months occurred in 23 patients during follow-up: 18 with asymptomatic periods of more than 1 year were pain free at the time of study and 5 with asymptomatic periods of 3 to 6 months had infrequent pain. Ten patients had no asymptomatic periods. Symptomatic status at last review was related to initial response to therapy: 13 of 18 patients (72%) currently asymptomatic became asymptomatic with initial therapy compared with 5 of 15 patients (33%) currently experiencing pain (p = 0.06). Twenty-six patients were currently receiving therapy: 22 verapamil, 80 to 640 mg/day (mean 280), 2 nifedipine, 1 diltiazem and amiodarone and 1 isosorbide (15 were receiving additional isosorbide). Twelve patients were not receiving therapy or were receiving very low dosage therapy, including 8 with asymptomatic periods of more than 1 year. Patients with coronary spasm and less than 70% diameter narrowing treated medically have low mortality and morbidity rates over 5-year follow-up. Many have long asymptomatic periods and some may be able to stop therapy indefinitely.     

Tumour excision plus continuous tamoxifen compared with modified radical mastectomy in patients over 70 years of age with operable breast cancer

Between 1985 and 1991, we randomly assigned 77 women over the age of 70 years with stage I-3a breast cancer to undergo a modified radical mastectomy or tumour excision followed by tamoxifen. Median follow-up was 45 months. Patients treated by tumour excision and tamoxifen had a significantly better survival (P = 0.04). The disease-free survival of the tumour excision and tamoxifen group was close to significantly better (P = 0.10). Only two patients in the tamoxifen group required an axillary dissection on follow-up for progressive nodal enlargement. Two patients underwent a local mastectomy for locally recurrent disease. We conclude that tumour excision followed by continous tamoxifen is an acceptable, safe alternative to a modified radical mastectomy in patients over 70 years of age.     

Primary osteosarcoma of the breast

The typical clinical and diagnostic imaging features of primary osteosarcoma of the breast are presented. © 1993 Wiley-Liss, Inc.     

Spiral growth of the laminar shell of the brachiopod Crania

The secondary (inner) shell of the brachial valve ofCrania is composed of tablets (laminae) of calcite separated from one another by protein sheets and forming a regular succession of alternating organic and inorganic layers. The succession is not deposited in sequence layer by layer. Instead the laminae grow laterally, usually at more than one level, by accretion from an extrapallial fluid along edges defined by screw dislocation. Simultaneously protein is exuded from the same extrapallial fluid to form sheets on the surfaces of the expanding laminae so that the protein sheets not only are continuous with one another but also generally pass from one level to the next spirally around dislocation lines. Outer epithelial cells secreting the extrapallial fluid are attached to the protein sheets by desmosomal connections, but these can be broken as centres of deposition shift around in relationship to the plasmalemmas of the secreting cells.

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Zusammenfassung Die sekundäre (innere) Schale der brachialen Klappe vonCrania besteht aus Calcitplättchen (Laminae), die voneinander durch Proteinblätter getrennt sind und eine regelmäßige Folge von abwechslungsweise organischen und anorganischen Schichten bilden.Die Ablagerung erfolgt nicht schichtweise, sondern die Plättchen wachsen seitlich, meistens auf mehreren Ebenen, durch Zuwachs aus einer extrapallialen Flüssigkeit entlang den Kanten, die durch spiralförmige Verschiebungen gekennzeichnet sind. Gleichzeitig wird Protein aus derselben extrapallialen Flüssigkeit ausgeschieden; daraus entstehen an der Oberfläche der sich ausdehnenden Laminae Proteinblätter, welche nicht nur zusammenhängend sind, sondern im allgemeinen sich auch von einer Ebene auf die nächste ausdehnen, indem sie sich spiralförmig um die Verschiebungslinie legen. Äußere Epithelialzellen, welche die extrapalliale Flüssigkeit sezernieren, werden den Proteinblättern mittels Protoplasmabrücken angefügt, die letzteren können jedoch zerstört werden, da im Zusammenhang mit den Plasmalemma der sezernierenden Zellen die Ablagerungszentren verschoben werden.

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Résumé Le coquille secondaire (interne) de la valve brachiale deCrania est composée de plaquettes (lamelles) de calcite, séparées l'une de l'autre par des membranes protéiques et formant une succession régulière de couches organiques et inorganiques. Une telle série n'est pas formée couche par couche, l'une aprés l'autre. Au contraire, les lamelles se développent latéralement, généralement à plus d'un niveau, par accroissement dans un liquide extrapallial le long des côtes définis par des dislocations hélicoidales. Simultanément, les membranes protéiques sont déposées dans le même liquide extrapallial sur les surfaces des lamelles en voie de développement, de sorte que non seulement elles sont continues l'une avec l'autre, mais encore elles passent d'un, niveau à l'autre de facon spiralée le long de lignes de dislocation. Les cellules épithéliales, qui sécrètent le liquide extrapallial, sont attachées aux membranes protéiques par des desmosomes, mais ceux-ci peuvent être rompus au fur et à mesure de la migration des centres de déposition par rapport auxmembranes cytoplasmiques des allules sécrétantes.