Efficiency of prostate-specific antigen and digital rectal examination in screening, using 4.0 ng/ml and age-specific reference range as a cutoff for abnormal values

BACKGROUND: The purpose of this study was to examine the diagnostic efficiency of prostate-specific antigen (PSA) and digital rectal examination (DRE) testing when using either 4.0 ng/ml or an age-specific reference range (ASRR) as an abnormal cutoff PSA value. METHODS: Between 1992-1995, 116,073 men, aged 40-79 years, were screened during Prostate Cancer Awareness Week. When using a 4.0-ng/ml cutoff PSA value, 22,014 had either an abnormal PSA, an abnormal DRE, or both. When using an ASRR cutoff PSA value, 17,561 had either an abnormal PSA, an abnormal DRE, or both. The positive predictive value (PPV), sensitivity, and specificity of PSA, DRE, and combined PSA and DRE tests were evaluated. RESULTS: When using a 4.0-ng/ml cutoff PSA value, the PPVs of abnormal PSA alone, abnormal DRE alone, and combined abnormal PSA and DRE tests were 27.7%, 17.7%, and 56.0%, respectively. Sensitivities were 34.9%, 27.1%, and 38.0%, respectively. Specificities were 63.1%, 49.0%, and 87.9%, respectively. When using an ASRR cutoff PSA value, the PPVs of each category were 31.8%, 20.8%, and 63.7%, respectively. Sensitivities were 27.1%, 41.0%, and 31.8%, respectively. Specificities were 75.0%, 32.8%, and 92.2%, respectively. The PPVs of the PSA test were higher than those of the DRE. The PPVs of combined tests were highest when using either a 4.0-ng/ml cutoff PSA value or an ASRR cutoff PSA value (all P < 0.001). When using an ASRR, the PPVs of PSA, DRE, and combined tests were higher than those when using a 4.0-ng/ml without statistical significance (all P > 0.05). Sensitivity of PSA when using an ASRR was lower than when using 4.0 ng/ml. CONCLUSIONS: Significantly higher PPVs indicated that utilizing both a PSA test and a DRE is most effective in screening for the early detection of prostate cancer. Although higher PPVs when using an ASRR cutoff PSA value suggested fewer unnecessary biopsies, lower sensitivities resulted in fewer cancers detected. Thus, we recommend that the combination of a PSA test with a cutoff value of 4.0 ng/ml and a DRE should continue to be utilized in the screening programs.     

Results of chimney modification technique in ureterointestinal anastomosis of Hautmann ileal neobladder in bladder cancer

BACKGROUND: To evaluate the surgical technique and functional outcome of a new application of the chimney modification to the popular Hautmann ileal neobladder. This modification used 3-5 cm chimney tubularized ileal segment for the bilateral ureterointestinal anastomosis. METHODS: Between December 2000 and July 2004, 15 patients (14 men, 1 woman) with invasive bladder cancer underwent radical cystectomy and Hautmann neobladder with chimney modification at Siriraj Hospital, Bangkok. Mean age was 61.7 years (range, 43-72 years). Perioperative morbidity, early and late urinary diversion-related complications, other surgical complications, follow-up results of ureterointestinal anastomosis, renal function and metabolic disorders were evaluated. Patients were interviewed about their continence, voiding function and potency. RESULTS: At a mean follow-up of 29.5 months, two patients had died of cancer progression. Of the 15 patients, nine (60%) had 10 early complications. Eight complications were related to the neobladder and two were not. Three (20%) patients had three late complications. Two complications were neobladder-related and one was not. There was no perioperative mortality. There was no ureteroileal anastomosis stricture in this series. Neobladder-ureteral reflux was demonstrated in eight of 22 ureteral units in 11 patients in whom cystography was performed. All patients had normal upper urinary tract without evidence of urinary obstruction. All 14 men (93% of study sample) had spontaneous urination, normal renal function and no metabolic acidosis. Good and satisfactory continence in the day and night were 93% and 73%, respectively. All male patients experienced impotence postoperatively. Only one sought treatment and was successfully treated with sildenafil. The one woman in this study required intermittent catheterization to empty the neobladder completely. She also had renal insufficiency with serum creatinine of 2.2 mg/dL and hyperchloraemic metabolic acidosis. CONCLUSION: New chimney modification in Hautmann ileal neobladder is simple and safe. Complications are acceptable. Follow-up results of renal and voiding functions are satisfactory. This operation can maintain good quality of life for patients with bladder cancer undergoing radical cystectomy.     

Fine-needle aspiration cytology predicts inguinal lymph node metastasis without antibiotic pretreatment in penile carcinoma

OBJECTIVE: To evaluate the accuracy of fine-needle aspiration (FNA) cytology of palpable inguinal lymphadenopathy before definitive management of the primary tumour, in predicting inguinal lymph node (LN) metastasis in men with primary squamous cell carcinoma (SCC) of the penis. PATIENTS AND METHODS: Sixteen men with primary SCC of the penis and palpable inguinal lymphadenopathy (unilateral or bilateral) were treated by primary resection and bilateral inguinal LN dissection. FNA cytology was analysed for 25 palpable inguinal LNs at the time of penile biopsy. The sensitivity, specificity and accuracy of FNA cytology was compared with the histological findings from surgical LN clearance. RESULTS: The 25 FNAs were without complication and without evidence of implantation of metastasis in the needle tracts; 14 FNA samples were positive for metastasis, 10 were negative, and one was inconclusive. From the histological assessment of the surgical inguinal LN specimens, FNA cytology had a sensitivity of 93%, and specificity of 91% in predicting metastatic disease. CONCLUSION: FNA cytology of palpable inguinal lymphadenopathy before surgery for the primary tumour has a high sensitivity and specificity for metastatic penile cancer. This procedure permits early inguinal lymphadenectomy where appropriate without need for prolonged initial antibiotic treatment.     

Outcomes of radical prostatectomy in thai men with prostate cancer

OBJECTIVE: Radical prostatectomy remains the standard treatment for early prostate cancer. Few data in the literature are from South East Asia. This study was conducted to evaluate the outcome of radical prostatectomy in Thai men. METHODS: A total of 151 patients with prostate cancer underwent radical prostatectomy at Siriraj Hospital, Bangkok, between 1994 and 2003. Clinical staging, preoperative prostate-specific antigen (PSA) and Gleason score were evaluated with pathological stage and margin status. Follow-up PSA monitoring and survival were analysed. RESULTS: Of 121 patients with clinical localized disease, 79 (65.3%), 40 (33.1%) and two (1.6%) had localized, locally advanced and metastatic disease, respectively, on pathology. The chance of localized disease with a preoperative PSA of 10 ng/mL or less, more than 10-50 ng/mL and more than 50 ng/mL was 75.5%, 50% and 12.5%, respectively (all p < 0.001). The chance of localized disease with a Gleason score of 2-4, 5-7 and 8-10 was 85%, 55.1% and 20.8%, respectively (all p < 0.02). Mean follow-up was 30 months. Among 140 evaluable patients, 51 (36.4%) had adjuvant therapy and 136 (97.1%) had undetectable PSA without clinical progression. The cumulative PSA progression-free survival among patients with pathological T1N0, T2N0 and T3N0 disease was 0.83 at 82 months, 0.48 at 85 months and 0.31 at 57 months, respectively. CONCLUSION: Radical prostatectomy in Thai men shows excellent results. The trend is the same as in Western series. The chance of organ-confined disease and free margin was high in patients with clinical T2 or less, PSA less than 10 ng/mL and low Gleason score. PSA progression-free survival was high in patients with organ-confined disease.     

Surgical treatment of renal cell carcinoma with inferior vena cava thrombus: using liver mobilization technique to avoid cardiopulmonary bypass

OBJECTIVE: To evaluate the results of surgical treatment of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus and describe the use of a transabdominal approach with liver mobilization to avoid cardiopulmonary bypass (CPB). METHODS: From February 2002 to January 2006, 109 patients with RCC were surgically treated at Siriraj Hospital. Twelve patients had an IVC thrombus, infrahepatic (level I), retrohepatic (level II), suprahepatic (level III) and intra-atrial (level IV) in one, two, eight and one patient, respectively. Patients' characteristics, pathological features, survival and morbidity were evaluated. RESULTS: Mean age was 58 years (range, 37-74 years). CPB was used in one patient with level IV thrombus. All patients (92%) with level I-III IVC thrombi underwent successful removal by transabdominal approach without any form of bypass. Mean operative time was 302 minutes (range, 195-420 minutes). The mortality rate was 16% (2 of 12) with sepsis and pulmonary embolism. One patient had colonic injury requiring primary repair. At the mean follow-up of 17 months (range, 3-35 months), of 10 patients, one died due to distant metastases, two were lost to follow-up and seven (60%) were still alive. Five patients (42%) were disease-free at the last follow-up. CONCLUSION: These results support the aggressive surgical removal of RCC with IVC thrombus as the initial treatment. Most of the thrombi can be approached and safely controlled by a transabdominal approach without any form of bypass. Tumour thrombus removal provides a high survival chance and offers improvement in quality of life.