Diagnostic uncertainty expressed in prostate needle biopsies. A College of American Pathologists Q-probes Study of 15,753 prostate needle biopsies in 332 institutions.

OBJECTIVE: To determine the rate of diagnostic uncertainty in rendering diagnoses on prostate needle biopsies and to examine pathology practice variables that influence that rate. DESIGN: Anatomic pathology departments participating in the College of American Pathologists Q-Probes laboratory quality improvement program retrospectively reviewed their last 50 consecutive prostate needle biopsy diagnoses. For each diagnosis, participants provided information concerning patients' prostate-specific antigen levels; number, locations, and laterality of biopsy specimens; number of tissue levels examined; performance of high-molecular-weight cytokeratin immunoperoxidase staining; and acquisition of consultations from general pathologists or experts in prostate pathology. Characteristics of pathology practices included yearly surgical and prostate needle biopsy caseloads, number of pathologists rendering biopsy diagnoses, use of standard descriptive checklists, access to patients' prostate-specific antigen and digital rectal examination results, percentages of prostate needle biopsies routinely submitted for internal consultations, and presence of departmental experts in prostate pathology. SETTING AND PARTICIPANTS: Three hundred thirty-two public and private institutions located in the United States (n = 318), Canada (n = 6), Australia (n = 5), United Kingdom (n = 2), and Guam (n = 1). MAIN OUTCOME MEASURE: The rate of diagnostic uncertainty in prostate needle biopsy diagnoses. RESULTS: Participants submitted diagnoses on a total of 15 753 prostate needle biopsy cases, of which 33.4% were adenocarcinoma; 55.5% were benign; 3.9% were carcinoma in situ, prostatic intraepithelial neoplasia, or both; and 7.1% were diagnostically uncertain. The median rate of diagnostic uncertainty was 6%, ranging from 0 at the 10th percentile to 14% at the 90th percentile of all participating laboratories. Performing high-molecular-weight cytokeratin immunoperoxidase staining resolved diagnostic uncertainty in 68% of cases in which it was performed, and obtaining intradepartmental and extradepartmental consultations resolved diagnostic uncertainty in 70% to 87% of cases for which they were obtained. Knowledge of patients' prostate-specific antigen results and examining multiple biopsy cores had marginal effects on the rate of uncertainty. Thoroughness of prostate gland sampling and examination of multiple tissue block levels were not associated with the aggregate rate of diagnostic uncertainty. We found no particular pathology departmental practices or institutional demographic characteristics associated with institutional rates of diagnostic uncertainty. CONCLUSIONS: Use of high-molecular-weight cytokeratin immunoperoxidase staining and obtaining intradepartmental and extradepartmental consultations may be effective in reducing diagnostic uncertainty in prostate biopsies.

Prevalence of Campylobacter pylori in esophagitis, gastritis, and duodenal disease.

The relationship between the presence of Campylobacter pylori and esophagitis was studied in patients undergoing paired biopsies of distal esophagus and gastric antrum during esophagogastroduodenoscopy. Biopsy specimens were examined for urease activity and for the presence of C pylori by culture and by histologic examination of hematoxylin-eosin- and Warthin-Starry-stained sections. Sixty-two patients were entered into the study. All esophageal biopsy specimens, regardless of histologic findings, were negative for the presence of C pylori by urease test, culture, and histologic examination. Of 35 patients with normal esophageal biopsy specimens, 11 (31%) had antral specimens that were positive for C pylori, while 11 (41%) of the 27 patients with esophagitis had antral specimens that were positive for the organism. Campylobacter pylori was detected in 14 (70%) of 20 patients with chronic gastritis, in 8 (67%) of 12 patients with endoscopically documented duodenal ulcers and erosions, but in only 3 (33%) of 9 patients with endoscopically defined duodenitis. We conclude that histologic esophagitis is not associated with increased prevalence of either gastric or esophageal C pylori. The well-described association of chronic gastritis and duodenal ulcers with C pylori was present in our study population.

Purulent pericarditis caused by Candida: report of three cases and identification of high-risk populations as an aid to early diagnosis.

Purulent pericarditis due to fungal organisms is rare and often unrecognized because of the subtle clinical clues and insidious onset. The records of 11 cases of purulent pericarditis were selected from records of 11,000 cases of pericarditis at Duke University Medical Center and reviewed, and experience with three cases of candida purulent pericarditis (CPP) was evaluated. One case occurred in a patient recovering from complicated cardiac surgery, one in a patient with hematologic malignancy, and one in an alcoholic patient requiring intubation for a severe respiratory infection. Each case is representative of a group at increased risk for the development of CPP. Given the poor prognosis for CPP, treatment should include both medical and surgical interventions. Although amphotericin B achieves good penetration into the inflamed pericardial space, the only survivors of CPP have received both amphotericin B and pericardiectomy. Careful attention to clinical indications of pericardial inflammation and systemic infection in the three groups of patients may lead to earlier recognition of CPP, implementation of appropriate therapy, and perhaps a higher rate of cure.

Primary intranasal Fusarium infection. Potential for confusion with rhinocerebral zygomycosis.

Fusarium species are saprophytic fungi that may colonize human skin and nails and may rarely cause invasive infections in traumatized tissue and in debilitated and immunocompromised patients. We report herein a case of invasive intranasal Fusarium oxysporum infection in a diabetic patient. This unusual presentation potentially can be confused with early rhinocerebral zygomycosis clinically and histologically. Distinguishing morphologic features and the possible role of diabetes in promoting this infection are discussed.