Comparing negative health indicators in male and female veterans with the Canadian general population.

INTRODUCTION: Sex-based information on differences between Canadian veterans and the general population is important to understand veterans' unique health needs and identify areas requiring further research. This study compared various health indicators in male and female veterans with their Canadian counterparts. METHODS: Health indicators for recent-era Regular Force veterans (released between 1998 and 2015) were obtained from the 2016 Life After Service Survey and compared with the general population in the 2015-16 Canadian Community Health Survey using a cross-sectional approach. Age-adjusted rates and 95% CIs were calculated for males and females separately. RESULTS: Compared with Canadians, veterans (both sexes) reported higher prevalence of fair or poor health and mental health, needing help with one or more activity of daily living, lifetime suicidal ideation and being diagnosed with mood and anxiety disorders, post-traumatic stress disorder, migraines, back problems, chronic pain, arthritis, ever having cancer, hearing problems, chronic pain and gastrointestinal problems. A higher prevalence of cardiovascular disease (all types) and high blood pressure was observed in male veterans compared with their Canadian counterparts. Within veterans only, males reported a higher prevalence of diagnosed hearing problems and cardiovascular disease compared with females; conversely females reported a higher prevalence of diagnosed migraines, mood, anxiety and gastrointestinal disorders, and needing help with activities of daily living. These sex differences are similar to the Canadian general population. Some similarities in reporting prevalence between male and female veterans (eg, fair or poor mental health, lifetime suicidal ideation, arthritis, asthma, lifetime cancer incidence, chronic pain and diabetes) were not observed in other Canadians. CONCLUSION: Male and female veterans differed from comparable Canadians, and from each other, in various areas of health. Further research is needed to explore these findings, and veteran-based policies and services should consider sex differences.

Robotic retroperitoneal lymph node dissection for primary and post-chemotherapy testis cancer.

The role of retroperitoneal lymph node dissection (RPLND) in testicular cancer is well established in both the primary and post-chemotherapy setting. The aim of this study was to report our 2 years oncological outcomes of robotic RPLND. A retrospective review was performed of all patients undergoing robotic RPLND by a single surgeon at Princess Margaret Cancer Centre. Demographic, perioperative, and oncologic data were analyzed using descriptive statistics. Between September 2014 and June 2020, 141 patients underwent an RPLND [33 (23.4%) were primary, 108 (76.6%) were post-chemotherapy]. 27 (19.1%) patients underwent a robotic bilateral template nerve-sparing RPLND. RPLND indication was primary (i.e. pre-chemotherapy) in 18 (66.7%), and post-chemotherapy in 9 (33.3%) patients. Stage at RPLND was 2A (n = 15, 55.6%), 2B (n = 9, 33.3%), 2C (n = 1, 3.7%) and 3 (n = 2, 7.4%). Median OR time (incision to closure) was 525 min and blood loss was 200 ml. Nerve sparing was performed in all but one case. Six (22.2%) adjuvant procedures were performed including two (7.4%) vascular repairs. Median length of stay was 2 days. Viable tumor was detected in 17 (63%) and teratoma in 9 (33.3%). Median follow-up was 31.3 months. No adjuvant chemotherapy was given. Three patients (11.1%) relapsed: 2 out-of-field and 1 with both in-field and out-of-field disease. Robotic RPLND can be performed safely. Long-term follow-up of series such as ours, enriched with patients with viable disease and/or teratoma, and not treated with adjuvant chemotherapy is required to ensure oncological outcomes are comparable to the open approach.

Partial orchiectomy: The Princess Margaret cancer centre experience.

INTRODUCTION: Radical orchiectomy (RO) is the standard treatment for a testis cancer. Organ sparing surgery can be considered in the setting of a solitary functioning testis or bilateral tumors. It has also been suggested as an alternative to RO for small lesions. In this study we report our partial orchiectomy (PO) experience. METHODS: We performed a retrospective review using our prospectively maintained database analyzing PO. RESULTS: Between 1983 and 2018, 77 patients underwent PO. Mean age was 31.3 years (range 17-56). A lesion was palpable in 70 (90.9%) and median lesion size 14.1 mm (range 3-35 mm). Reasons for PO included ``small lesion" in 39 (50.6%); solitary functioning testis in 30 (39%); bilateral lesions in 6 (7.8%); or assumed benign lesion in 1 (1.3%). Median follow-up was 43.5 months (range 1-258). Lesion histology was benign in 25 (32.5%). A positive surgical margin was noted in 6 (7.8%) with none developing local or distant recurrence. Sixteen (20.8%) patients underwent salvage ipsilateral RO at a median of 3 months (range 0-46). Reasons for salvage RO included a radiologically detected lesion in 7, palpable lesion in 4, positive surgical margin in 3 and adverse pathology in 2 patients. Malignant histology was present in 12 (75%) of the salvage RO specimens. There were no reported Clavien-Dindo Grade 3 to 5 complications. CONCLUSION: Organ sparing surgery is a safe and feasible approach to small testis lesions. For the third with benign disease, and even those with malignant histology, a RO can be avoided in carefully selected patients.

Clinical Characteristics and Outcomes of Late Relapse in Stage I Testicular Seminoma.

AIMS: To identify the characteristics and outcomes associated with late relapse in stage I seminoma. MATERIALS AND METHODS: A retrospective review was carried out of all patients with stage I seminoma managed at our institution between 1981 and 2011. Data were obtained from a prospectively maintained database. Late relapse was defined as tumour recurrence > 2 years after orchiectomy. RESULTS: Overall, 1060 stage I seminoma patients were managed with active surveillance (n=766) or adjuvant radiotherapy (n=294). At a median follow-up of 10.6 years (range 1.2-30), 142 patients relapsed at a median (range) of 14 (3-129) months; 128 on active surveillance and 14 after adjuvant radiotherapy. The late relapse rate for the active surveillance and adjuvant radiotherapy groups was 4% and 1%, respectively. There was no specific clinicopathological factor associated with late relapse. Isolated para-aortic node(s) was the most common relapse site in active surveillance patients either in late (88%) or early relapse (82%). Among the active surveillance group, no patients with late relapse subsequently developed a second relapse after either salvage radiotherapy (n=25) or chemotherapy (n=6), whereas in early relapse patients a second relapse was reported in seven (10%) of 72 patients treated with salvage radiotherapy and one (4%) of 23 patients who received chemotherapy; all second relapses were subsequently salvaged with chemotherapy. No patient in the adjuvant radiotherapy group developed a second relapse after salvage chemotherapy (n=10) or inguinal radiotherapy/surgery (n=4). Of seven deaths, only one was related to seminoma. Among active surveillance patients, the 10 year overall survival for late and early relapse groups were 100% and 96% (P = 0.2), whereas the 10 year cancer-specific survival rates were 100% and 99% (P = 0.3), respectively. CONCLUSIONS: In stage I seminoma, the extent and pattern of late relapse is similar to that for early relapse. For active surveillance patients, selective use of salvage radiotherapy/chemotherapy for relapse results in excellent outcomes regardless of the timing of relapse, whereas salvage radiotherapy for late relapse seems to be associated with a minimal risk of second relapse.

A pilot 'window of opportunity' neoadjuvant study of metformin in localised prostate cancer.

BACKGROUND: Metformin is an inhibitor of complex 1 in the respiratory chain, and is widely used to reduce insulin resistance. It has also been described to have pleotropic effects including via AMPK on inhibiting the mTOR kinase. Pre-clinical and epidemiological studies suggest an ability to modulate disease evolution in prostate cancer. In this study, we aimed to (i) demonstrate safety and tolerability of neoadjuvant metformin administration and (ii) document changes in proliferative (Ki67) and AMPK-related signalling indices between matching biopsies and prostatectomies METHODS: Men were treated in a single-arm 'window of opportunity' study between their decision to undergo radical prostatectomy and the operation itself. Forty patients were planned but only 24 patients were enrolled owing to slow accrual. Twenty-one patients were evaluable for pathological outcomes and 22 for serum metabolic indices. Metformin was given at doses to 500 mg t.i.d. Ki67 index was calculated using the Aperio-positive pixel count algorithm, whereas immunohistochemical measurements were by consensus H-Score. Comparative statistics were analysed by students t-tests and/or Wilcoxon matched pairs signed rank test. RESULTS: Baseline characteristics included median PSA 6 ng ml(-1) (3.22-36.11 ng ml(-1)). Median duration of drug treatment was 41 days (18-81). Treatment was well tolerated with only three patients developing G3/4 toxicities. In a per patient and per tumour analyses, metformin reduced the Ki67 index by relative amounts of 29.5 and 28.6 % (P=0.0064 and P=0.0042) respectively. There was also a significant decrease in P-4EBP1 staining (P<0.001) but no change in P-AMPK or P-ACC. There were no correlations between any metabolic, morphometric or cancer-related serum indices. There was a trend towards PSA reduction (P=0.08). The study is limited by small patient numbers and tumour heterogeneity. CONCLUSIONS: Neoadjuvant metformin is well tolerated prior to radical prostatectomy. Data to date indicate promising effects on metabolic and tissue proliferation and signalling parameters.

A unique renal lesion in common variable immunodeficiency.

This article reports the case of a 33-year-old woman with common variable immunodeficiency (CVI) who developed renal failure 17 years after diagnosis and initiation of treatment with monthly IVIG. A renal biopsy revealed mesangial and paramesangial immune complex deposition and interstitial granulomatous infiltration. Renal function improved with oral corticosteroids, but did not return to normal. Decreasing the dose of IVIG had no effect on renal function. Immune dysfunction can be associated with both granulomatous disease and immune complex glomerulonephritis, or the latter may be related to chronic infection or immunoglobulin use. This is the first report of concomitant glomerular-tubulointerstitial lesions in this immunodeficiency syndrome. Renal function should be closely followed in patients with CVI.

Development of a radiofrequency based thermal therapy technique in an in vivo porcine model for the treatment of small renal masses.

PURPOSE: Incidentally detected small renal tumors appear to grow slowly and be localized to the kidney. Minimally invasive therapies are being investigated as alternatives to standard surgical techniques. Radiofrequency ablation has been reported for the treatment of small renal cell carcinomas. We developed a radiofrequency technique and established its efficacy and safety in a large animal model. METHODS AND METHODS: A total of 22 lesions were created in normal kidneys of 7 pigs. Radiofrequency energy was administered during open exposure of the kidneys or percutaneously under ultrasound guidance. Lesion development was monitored with gray-scale and power Doppler ultrasound. To avoid heating surrounding tissues new hydro-dissection and gas-dissection techniques were developed. Lesion sizes and characteristics were assessed by ultrasound and pathological examination. RESULTS: No complications were observed due to probe insertion and removal. Perirenal structures were thermally damaged before the development and application of the dissection techniques. Lesion size was accurately predicted by gray-scale ultrasound on day 7. Loss of perfusion in the ablated volume was confirmed by power Doppler ultrasound. Lesions were wedge-shaped, presumably due to the effects of heating on segmental blood flow distribution. Pathological examination revealed changes consistent with thermal injury and ischemic type infarction. CONCLUSIONS: Radiofrequency thermal therapy is an effective and efficient method for ablating normal renal tissue in the pig. It may be applied percutaneously under ultrasound guidance with minimal complications provided that vital adjacent structures are protected from thermal damage. Further studies are required in humans before adopting this technique as definitive treatment for small renal cell carcinoma.

Sonochemical synthesis of iron phosphide.

The sonochemical reaction of Fe(CO)5 and triethylphosphine has been found to produce solid amorphous iron phosphide of composition FeP. The resulting compound was characterized by elemental microanalysis, scanning electron microscopy, energy-dispersive X-ray analysis, and Debye-Scherrer powder X-ray diffraction. X-ray powder patterns were obtained after the amorphous material had been heated above 950 degrees C and then slowly cooled to induce crystallization. This reaction provides the first use of ultrasound to sonochemically synthesize amorphous phosphide semiconductor materials from organometallic precursors.

Evidence of chromosomal instability in prostate cancer determined by spectral karyotyping (SKY) and interphase fish analysis.

The way in which cytogenetic aberrations develop in prostate cancer (CaP) is poorly understood. Spectral karyotype (SKY) analysis of CaP cell lines has shown that they have unstable karyotypes and also have features associated with chromosomal instability (CIN). To accurately determine the incidence of de novo structural and numerical aberrations in vitro in CaP, we performed SKY analysis of three independent clones derived from one representative cell line, DU145. The frequent generation of new chromosomal rearrangements and a wide variation in the number of structural aberrations within two to five passages suggested that this cell line exhibited some of the features associated with a CIN phenotype. To study numerical cell-to-cell variation, chromosome 8 aneusomy was assessed in the LNCaP, DU145, and PC-3 cell lines and a patient cohort of 15 CaP primary tumors by interphase fluorescence in situ hybridization (FISH). This analysis showed that a high frequency of numerical alteration affecting chromosome 8 was present in both in vitro and in CaP tissues. In comparison to normal controls, the patient cohort had a statistically significant (P<.05), greater frequency of cells with one and three centromere 8 copies. These data suggest that a CIN-like process may be contributing towards the generation of de novo numerical and structural chromosome abnormalities in CaP.

V89L polymorphism of type-2, 5-alpha reductase enzyme gene predicts prostate cancer presence and progression.

OBJECTIVES: The valine (V) to leucine (L) polymorphism of the SRD5A2 gene is associated with 5-alpha reductase-2 activity; patients with the V allele have high activity and patients with the L allele have low activity. We examined whether this polymorphism predicts the presence of prostate cancer in 320 men without cancer who underwent biopsy and cancer progression in 318 men who underwent radical prostatectomy. METHODS: The effect of the SRD5A2 gene in predicting the presence of prostate cancer was examined using logistic regression analysis, controlling for established risk factors. The effect of the SRD5A2 gene in predicting prostate cancer progression was examined using a nested, matched, case-control design. Most of the participants were white. RESULTS: Of the 320 men, 158 (49.4%) were found on biopsy to have prostate cancer. The overall distribution of the V/V, V/L, and L/L genotypes was 47.5%, 42.5%, and 10.0%, respectively. The adjusted odds ratio for having prostate cancer for patients with at least one V allele was 2.53 compared with patients with the L/L genotype (P = 0.03). Of the 318 patients with cancer, 80 had biochemically detected recurrence and 238 had no evidence of recurrence. The odds ratio for progression for patients with at least one V allele was 3.32 (95% confidence interval 1.67 to 6.62, P = 0.0006) compared with patients with the L/L genotype. CONCLUSIONS: Men who have the V allele of the SRD5A2 gene have a twofold increase in the risk of prostate cancer development and an additional twofold increase in the risk of progression compared with men with the L/L genotype.

Significance of the CAG repeat polymorphism of the androgen receptor gene in prostate cancer progression.

PURPOSE: The CAG repeat polymorphism of the androgen receptor gene has been associated with an increased prostate cancer risk, and the repeat length correlated with cancer stage and grade at presentation. Men with an allele length of 18 CAG repeats, controlling for grade, stage and serum PSA level at diagnosis using Cox proportional hazard modeling. RESULTS: Overall, the CAG repeat allele was not predictive of recurrence; tumor grade, stage and PSA level at diagnosis were the only predictors of recurrence in a multivariate analysis. However, for patients at low risk for recurrence (Gleason score 2 to 6, stage pT2, and PSA 18 CAG repeats. In contrast, for patients at high risk of recurrence (Gleason score >/= 7, stage pT3/4, or PSA >10 ng./ml.), the relative risk associated with the 18 CAG repeat allele. CONCLUSIONS: The length of the CAG repeat polymorphism of the androgen receptor gene may be important for prostate cancer recurrence among patients who are otherwise at low risk for recurrence after radical prostatectomy. These findings have potential implications for patient selection for adjuvant treatment, and for the development of novel treatments.

Standard off-cord lung oblique fields do not include the entire mediastinum: a computed tomography simulator study.

The routinely recommended target volume for off-cord lung oblique fields in the treatment of postoperative bronchogenic carcinoma includes the entire mediastinum, as defined by coverage of the contralateral mainstem bronchus and subcarinal space. However, this may be difficult to accomplish with the field angles of 20 degrees to 40 degrees, recommended in the recently completed Intergroup Trial (Radiation Therapy Oncology Group 91-05). This project was undertaken to define the oblique angle necessary to encompass the entire mediastinum as determined by computerized tomography simulator verification. Axial computerized tomography simulation images of 25 patients with non-small-cell lung cancer were used in this study. Ten patients had prior lobectomy or pneumonectomy as part of their management. The contralateral mainstem bronchus, subcarinal space (SS), and the spinal cord were each contoured as separate volumes. The length of the contralateral mainstem bronchus was defined as extending from the carina to the bifurcation of the lobar bronchi. The subcarinal space was defined as a triangular space (in a coronal plane) with the carina at the apex, the mainstem bronchi superiorly, and a horizontal line 5 cm below the carina as the base of the triangle. The minimal angle to encompass the contralateral mainstem bronchus and subcarinal space, and to exclude the spinal cord was determined for each patient. The contoured volumes did not have additional margin added. The position of the carina was scored as "midline" if located in the midsagittal plane, or "off-midline" if deviated to either side from midline. Midline deviation was determined at the level of the carina to evaluate possible anatomical distortion relating to the tumor or prior surgery, and its effect on the minimal angle was assessed. The median minimal angle measured was 45 degrees (range: 28-65 degrees) for the entire group, and in 64% of those evaluated, this oblique angle was significantly greater than the 40 degrees recommended in Radiation Therapy Oncology Group guidelines (p = 0.017). In patients without midline deviation (n = 17), the median minimal angle was 45 degrees (range: 28-60 degrees), and in patients with midline deviation (n = 8), it was determined to be 44 degrees (range: 27-65 degrees), with no statistical difference noted between the two groups (p = NS). Although midline deviation was present in 4 of 10 patients previously resected, the above relationship remained unchanged. Based on computerized tomography simulation verification, off-cord oblique field angles of 20 degrees to 40 degrees do not adequately cover the entire mediastinum in most patients. To adequately encompass the entire mediastinum as defined in the Intergroup Trial (Radiation Therapy Oncology Group 91-05) with off-cord oblique fields, treatment angles greater than 40 degrees are necessary. Whether the potential increase in lung volume exposed to radiation from these larger angles results in a poorer therapeutic ratio requires further investigation.

A comparative analysis of sextant and an extended 11-core multisite directed biopsy strategy.

PURPOSE: The 3 tumor locations unsampled by conventional sextant biopsies that have been identified on composite 3-dimensional reconstruction of 180 radical prostatectomy specimens are the anterior transition zone, midline peripheral zone and inferior portions of the anterior horn in the peripheral zone. We evaluated an 11-core multisite directed biopsy scheme incorporating these alternate areas and conventional sextant biopsies in 362 patients from 2 institutions. MATERIALS AND METHODS: Patients without a prior diagnosis of cancer underwent ultrasound guided 11-core biopsies which included conventional sextant and 3 alternate sites. All specimens were separated for specific location identification. Biopsy was performed in 183 patients at MD Anderson Cancer Center (group 1) and in 179 at Toronto General Hospital (group 2). All group 2 and 54% of group 1 patients (98 of 183) had a prior biopsy negative for cancer. RESULTS: Median prostate specific antigen was higher in group 2 than in group 1 patients (11.5 versus 9.5 ng./ml., p = 0.016). Overall a 33% increase (36 of 110 patients) in cancer detection was observed when biopsy technique included the alternate areas (p = 0.0021). The anterior horn was the most frequently positive biopsy site followed by the transition zone and midline sites. The 11-core technique had significantly better cancer detection rates when digital rectal examination and transrectal ultrasound were normal, and in men with serum prostate specific antigen between 4.1 and 10 ng./ml. CONCLUSIONS: Biopsies of the alternate sites suggested by our simulation studies are feasible and reproducible. This new strategy significantly enhanced (p = 0.0075) prostate cancer detection compared to conventional sextant biopsies in men undergoing a repeat procedure.

Radiation exposure to children during coil occlusion of the patent ductus arteriosus.

The risks of excessive exposure to ionizing radiation are well described and measures are routinely taken to limit such exposure to both patient and personnel in the catheterization laboratory. Coll occlusion of the patent ductus arteriosus (PDA) as well as other more complex pediatric interventions has raised concern regarding radiation exposure, particularly as minimally invasive surgical techniques are being developed which lack such exposure risk. In eight consecutive patients, aged 0.7-7 years (median, 2.3 years), coil occlusion of a PDA was performed and surface entrance radiation dose determined by thermoluminescent dosimetry (TD). Total cumulative doses (PA + lateral dose) were also calculated for each patient. Entrance and cumulative dose was likewise measured in 12 patients undergoing standard diagnostic catheterization (DC) and in 5 consecutive patients undergoing pulmonary balloon valvuloplasty (PBV). The groups were comparable in age, weight, and body surface area (BSA). Total cumulative dose in the PDA patients was 97 +/- 25 mGy (mean +/- SE). There was no significant difference between the three groups in entrance dose absorbed at each location or in total cumulative dose. The mean total fluoroscopy time in the PDA occlusion group was significantly less than that of the PBV group (10.1 +/- 1.81 min vs. 19.3 +/- 2.29 min, P < 0.05) but was comparable to the DC group (13.2 +/- 1.5 min, P = NS). When the subjects were analyzed collectively, no correlation between fluoroscopy time and measured entrance dose was observed. The strongest correlates of total cumulative dose were patient weight (r = 0.67, P < 0.001) and BSA (r = 0.62, P = 0.001). Patients undergoing coil occlusion of a PDA are not exposed to increased radiation entrance dose compared to those undergoing standard DC and PBV. Furthermore, surface entrance radiation dose as determined by TD varies according to patient size for a given fluoroscopy time.

Variation of clinical target volume definition in three-dimensional conformal radiation therapy for prostate cancer.

PURPOSE: Currently, three-dimensional conformal radiation therapy (3D-CRT) planning relies on the interpretation of computed tomography (CT) axial images for defining the clinical target volume (CTV). This study investigates the variation among multiple observers to define the CTV used in 3D-CRT for prostate cancer. METHODS AND MATERIALS: Seven observers independently delineated the CTVs (prostate +/- seminal vesicles [SV]) from the CT simulation data of 10 prostate cancer patients undergoing 3D-CRT. Six patients underwent CT simulation without the use of contrast material and serve as a control group. The other 4 had urethral and bladder opacification with contrast medium. To determine interobserver variation, we evaluated the derived volume, the maximum dimensions, and the isocenter for each examination of CTV. We assessed the reliability in the CTVs among the observers by correlating the variation for each class of measurements. This was estimated by intraclass correlation coefficient (ICC), with 1.00 defining absolute correlation. RESULTS: For the prostate volumes, the ICC was 0.80 (95% confidence interval [CI]: 0.56-0.96). This changed to 0.92 (95% CI: 0.75-0.99) with the use of contrast material. Similarly, the maximal prostatic dimensions were reliable and improved. There was poor agreement in defining the SV. For this structure, the ICC never exceeded 0.28. The reliability of the isocenter was excellent, with the ICC exceeding 0.83 and 0.90 for the prostate +/- SV, respectively. CONCLUSIONS: In 3D-CRT for prostate cancer, there was excellent agreement among multiple observers to define the prostate target volume but poor agreement to define the SV. The use of urethral and bladder contrast improved the reliability of localizing the prostate. For all CTVs, the isocenter was very reliable and should be used to compare the variation in 3D dosimetry among multiple observers.

Detection of RET mutations in multiple endocrine neoplasia type 2a and familial medullary thyroid carcinoma by denaturing gradient gel electrophoresis.

Germline missense mutations within the coding region of the RET proto-oncogene have recently been described in patients with the dominantly inherited cancer syndromes, multiple endocrine neoplasia type 2a (MEN 2a) and familial medullary thyroid carcinoma (FMTC). To date, the sequence variations occur in RET exons 10 and 11 and alter highly conserved cysteine residues in the proposed extracellular domain at codons 609, 611, 618, 620, and 634. To expedite rapid screening of populations at risk of MEN 2a or FMTC, we developed a PCR-based denaturing gradient gel electrophoresis (DGGE) strategy that detects polymorphisms occurring at all five Cys codons in both RET exons using identical gel conditions. In this report, the screening results from DGGE analysis of 15 distinct MEN 2a and FMTC mutations are shown. Each mutation generated a clearly distinguishable and unique homo- and heteroduplex band pattern. Given the highly efficient, reproducible, and sensitive nature of this approach, DGGE is particularly appropriate for rapid, large-scale screening of patients. Since prior knowledge of the RET mutation is unnecessary for analysis, DGGE is potentially valuable for distinguishing germline from seemingly sporadic medullary thyroid cancer as well as identifying novel sequence changes.

Differential diagnosis of steroid-dependent nephrotic syndrome with psychosis: Practical and ethical issues.

The present case illustrates practical and ethical issues that can be encountered by clinical psychologists providing consultation services in medical settings. The neuropsychological consultation service was asked to evaluate a 22-year-old male with psychosis, steroid-dependent nephrotic syndrome, and a family history of schizophrenia. MRI revealedmarked cortical atrophy. Clinical findings were consistent with (1) steroid inducedapparent atrophy, which has been shown to be reversible with withdrawal of steroids; (2) uremia secondary to steroid withdrawal; (3) cortical atrophy, found in some schizophrenics; or (4) an atypical, diffuse degenerative disorder. Clinical interview and psychological testing revealed significant thought disorder, prominent delusions, somatic hallucinations, and mood disturbance. Deterioration in social and academic functioning was also present. Except for impaired attention and concentration, neuropsychological evaluation showed no clear evidence of brain-based dysfunction. Further, neuropsychological results effectively ruled out a degenerative process and were not consistent with a steroid effects profile. A conclusive differential diagnosis of steroid induced psychosis versus severe psychopathology would require withdrawal from steroids and antipsychotics. In addition to the practical and ethical issues of withholding antipsychotics, steroid withdrawal would require either dialysis or renal transplant surgery. Decision making regarding dialysis dependency and the possibility of postsurgical psychosis secondary to true psychopathology were salient issues to both the patient and the treatment team.