Ferumoxytol-Enhanced MR Lymphography for Detection of Metastatic Lymph Nodes in Genitourinary Malignancies: A Prospective Study.

OBJECTIVE. The objective of our study was to evaluate the utility of ferumoxytol-enhanced MR lymphography (MRL) in detection of metastatic lymph nodes (LNs) in patients with prostate, bladder, and kidney cancer. SUBJECTS AND METHODS. This phase 2 single-institution study enrolled patients with confirmed prostate (arm 1), bladder (arm 2), and kidney (arm 3) cancer and evidence of suspected LN involvement. Participants underwent ferumoxytol-enhanced MRL 24 and 48 hours after IV injection of 7.5 mg Fe/kg of ferumoxytol. A retrospective quantitative analysis was performed to determine the optimal timing for ferumoxytol-enhanced MRL using percentage change in normalized signal intensity (SI) from baseline to 24 and 48 hours after injection, which were estimated using the linear mixed-effects model in which time (24 vs 48 hours), diseases status, and time and disease status interaction were the fixed-effects independent variables. Differences in normalized SI values between subgroups of lesions were estimated by forming fixed-effects contrasts and tested by the Wald test. RESULTS. Thirty-nine patients (n = 30, arm 1; n = 6, arm 2; n = 3, arm 3) (median age, 65 years) with 145 LNs (metastatic, n = 100; benign, n = 45) were included. LN-based sensitivity, specificity, positive predictive value, and negative predictive value of ferumoxytol-enhanced MRL was 98.0%, 64.4%, 86.0%, and 93.5%, respectively. Sensitivity and specificity of ferumoxytol-enhanced MRL did not vary by LN size. Metastatic LNs showed a significantly higher percentage decrease of normalized SI on MRL at 24 hours after ferumoxytol injection than at 48 hours after ferumoxytol injection (p = 0.023), whereas the normalized SI values for nonmetastatic LNs were similar at both imaging time points (p = 0.260). CONCLUSION. Ferumoxytol-enhanced MRL shows high sensitivity in the detection of metastatic LNs in genitourinary cancers independent of LN size. The SI difference between benign and malignant LNs on ferumoxytol-enhanced MRL appears similar 24 and 48 hours after ferumoxytol injection, suggesting that imaging can be performed safely within 1 or 2 days of injection. Although ferumoxytol-enhanced MRL can be useful in settings without an available targeted PET agent, issues of iron overload and repeatability of ferumoxytol-enhanced MRL remain concerns for this method.

Use of surgisis for abdominal wall reconstruction/closure in battlefield casualties during Operation Iraqi Freedom.

A case series and discussion based on experiences gained during Operation Iraqi Freedom are presented. The Army previously published an article on the use of Gore-Tex mesh in the staged closure of open abdominal wounds. We thought that use of a biomaterial could shorten the overall course of abdominal closure and improve outcomes. This is mainly a "proof of concept" type of study. Although class I data are not presented, a useful concept is discussed. To our knowledge, no other report of the use of biomaterials for battle casualties has been published. Several issues that are faced by the military medical system are presented. The use of Surgisis (lyophilized porcine small intestinal submucosa; Cook Biotech, West Lafayette, Indiana) in the described setting is presented as one possible solution.

Bile causing an acute scrotum immediately after laparoscopic cholecystectomy.

We report our experience with a patient that developed an acute right hemiscrotum immediately after undergoing an uncomplicated laparoscopic cholecystectomy for gallbladder dyskinesia. The etiology of the acute scrotal pain was due to bile which was spilled into the peritoneum after entry into the gallbladder during dissection. The bile obtained access to the right hemiscrotum via a communicating hydrocele. To the best of our knowledge this is the first report of bile causing an acute scrotum following laparoscopic surgery. A review of the current literature on the topic of the postoperative acute scrotum follows our case presentation.

Predictors of extracapsular extension and positive margins in African American and white men.

OBJECTIVE: Radical retropubic prostatectomy (RRP) pathology from African American (AA) and White men from 1988 to 1999 was examined to determine if the pre-treatment factors PSA, clinical stage, biopsy grade, age at surgery, and year of surgery (YOS) were predictive of extracapsular extension (ECE) and positive margins for each ethnic group. METHODS: Clinical and pathologic data was collected on 179 AA and 548 white men undergoing RRP from 1988 to 1999 at a tertiary military medical facility. Logistic regression with multivariate analysis was used to determine which pre-operative data-points were predictive of pathologic ECE and positive margins for each ethnic group. RESULTS: PSA, biopsy grade, age, and YOS (more recent years had better surgical pathology) were predictive of ECE for AA and white men. PSA, biopsy grade, and YOS were predictive of positive margins for AA men, while PSA and YOS were predictive of positive margins for white men. PSA continues to be a strong predictor of ECE and positive margins for both AA and white men. However, we describe for the first time, YOS being predictive of ECE and positive margins for both AA and White men, using multivariate regression analysis. CONCLUSION: This is thought to be reflective of the improving public awareness of prostate cancer that has occurred during the PSA-era, resulting in patients participating in screening programs and being diagnosed earlier. Close follow-up of these patients is warranted to determine if the improved pathologic stage of those patients treated more recently translates into improved disease-specific mortality.

The role of radical prostatectomy in patients with pretreatment prostate-specific antigen > or = 40 ng/mL.

OBJECTIVE: To assess the efficacy of radical prostatectomy (RP) in men presenting with markedly elevated prostate-specific antigen (PSA) levels, the records of 17 patients presenting with serum PSA values > or = 40 ng/mL, who underwent RP at Walter Reed Army Medical Center (WRAMC) between 1990 and 1995, were reviewed. METHODS: Pathologic and clinical data (staging, Gleason score, recurrences, adjuvant and neo-adjuvant treatment, most recent PSA value, urinary continence, and sexual function) for each patient was examined. The Kaplan-Meier method was used to analyze the disease-free survival (DFS) for PSA and clinical recurrence. Urinary continence and potency were also assessed. RESULTS: With a mean follow-up of 6.21 years (median 5.28 y), all 17 patients are alive. Five patients have no evidence of disease (NED), and 12 are alive with prostate cancer. Fifteen patients have PSA values between 0.1 and 3.0 ng/mL, and two patients have PSA values that have returned to pretreatment levels. Eleven patients received neo-adjuvant and/or adjuvant therapy. Fourteen men (82.3%) are continent and seven (41.1%) are potent. Survival analysis demonstrates a PSA DFS of 52.9% at five years and 26.5% at nine years; while, clinical DFS was 92.3% at five years and 58.0% at nine years. CONCLUSIONS: This study suggests a possible surgical role in treating patients presenting with significantly elevated PSA values. While surgery alone is unlikely to cure prostate cancer in these patients, surgery in conjunction with hormonal or radiation therapy may prolong survival with acceptable effects on urinary continence and potency.

Genitourinary trauma at a combat support hospital during Operation Iraqi Freedom: the impact of body armor.

PURPOSE: This report details the occurrences of genitourinary trauma experienced during Operation Iraqi Freedom at a United States Army Combat Support Hospital, and determines if wearing body armor decreases the frequency of genitourinary and specifically kidney trauma. MATERIALS AND METHODS: The Joint Theater Trauma Registry was used to conduct a retrospective study of 2,712 trauma admissions to a United States Army Combat Support Hospital in Baghdad, Iraq from April 1, 2005 to February 28, 2006. There were 1,216 casualties who were wearing body armor and 1,496 casualties not wearing body armor. RESULTS: Of the 2,712 trauma admissions 76 (2.8%) had 1 or more genitourinary injuries for a total of 98 genitourinary injuries. Of the 29 kidney injuries 2 (6.9%) were explored without any treatment, 7 (24.1%) were observed, 1 (3.4%) was repaired and 19 (65.5%) casualties required nephrectomy. Casualties wearing body armor had a 2.1% rate of genitourinary injury versus 3.4% not wearing body armor (p = 0.037). Casualties wearing body armor had a 0.5% rate of kidney injury compared to 1.4% not wearing body armor (p = 0.017). CONCLUSIONS: The percentage of casualties with genitourinary injuries and the distribution of these injuries appear similar to previous conflicts. The percentage of casualties undergoing nephrectomy appears to be greater than that observed in other recent conflicts. There was a significant reduction in overall genitourinary injuries and specifically kidney injuries in those casualties wearing body armor.

Comparison between lemonade and potassium citrate and impact on urine pH and 24-hour urine parameters in patients with kidney stone formation.

OBJECTIVES: The past few decades have been notable for advances in minimally invasive techniques to treat kidney stones. Despite successful surgical management of calculi, the impact of diet on stone disease prevention remains an important factor. Dietary modifications can be applied to prevent stone recurrence in an economical manner that is acceptable to patients. Lemonade has been studied in the past and found to increase urinary citrate levels in small groups of patients. The present study examined the effect of lemonade intake on a change in urinary pH and improvement of urinary stone risk factors compared with potassium citrate treatment. METHODS: A total of 21 stone-forming patients were treated with lemonade therapy and potassium citrate supplementation in a prospective cross-over trial. we performed 24-hour urine collections at baseline and with each treatment arm. the results between the two groups were examined to determine whether differences existed in the urinary stone risk factors. RESULTS: Potassium citrate, but not lemonade, improved citrate levels and urinary ph to a significant degree. patients taking potassium citrate had a significantly decreased urine volume compared with their urine volume drinking lemonade. neither lemonade nor potassium citrate affected the uric acid levels to a significant degree. CONCLUSIONS: The results of our study have shown that lemonade did not provide improvements in urinary citrate or pH levels but did assist patients in maintaining urine output compared with potassium citrate therapy.

Improved prostate cancer-specific survival and other disease parameters: impact of prostate-specific antigen testing.

OBJECTIVES: To determine how the implementation of prostate-specific antigen (PSA) testing has affected disease-specific survival and other characteristics of prostate cancer. METHODS: Data were collected on all patients with prostate cancer diagnosed between 1988 and 1998 and registered in the Center for Prostate Disease Research Database at Walter Reed Army Medical Center. Statistical analyses were used to summarize trends over time in survival, mortality, and clinical stage. RESULTS: Between 1988 and 1998, a total of 2042 patients with prostate cancer were registered at Walter Reed Army Medical Center. The 5-year disease-specific survival rate was 86.9% and 93.7% for patients diagnosed in the respective year groups of 1988 to 1991 and 1992 to 1994, with follow-up through December 1, 2000 (P < 0.001). Prostate cancer was the cause of death for 37.5% of the patients in 1988 to 1989 versus 15.4% in 1999 to 2000. Marked stage migration has occurred; from 1988 to 1998, the percentage of patients presenting with metastatic disease decreased from 14.1% to 3.3% (P < 0.001). CONCLUSIONS: A statistically significant improved 5-year disease-specific survival and a decreased chance of dying from prostate cancer has occurred after the widespread implementation of PSA. We suspect that PSA testing has resulted in fewer patients presenting with metastatic disease and more patients presenting with localized disease amenable to curative treatment. This portends well for the use of PSA screening to improve outcomes for prostate cancer. However, randomized trials are needed to confirm the improvements in survival and mortality.