Hematology and serum chemistry values of sooty mangabeys (Cercocebus atys): comparison with rhesus monkeys.

BACKGROUND: The sooty mangabey is a vulnerable West African species that naturally harbors simian immunodeficiency virus (SIV) without pathological symptoms. We present normative hematology and serum chemistry values for this species. METHODS: Hematology analytes from 136 females and 96 males and serum chemistry analytes from 57 females and 26 males were studied. RESULTS: Values of several analytes fell outside published reference ranges in the rhesus monkey, a laboratory standard for Old World primates. Erythrocyte-related parameters were higher in mangabeys than in rhesus monkeys, while platelet counts were lower. Mangabeys also had higher gamma-glutamyltransferase levels and lower urea nitrogen levels. Males had higher erythrocyte-associated values than females. Albumin, globulin, albumin/globulin ratio, calcium, and creatinine changed with age in patterns similar to those reported for the rhesus monkey. CONCLUSIONS: The unique blood profile of the mangabey should be taken into account in clinical and experimental studies of this species.

Prostate cryoablation using direct transperineal placement of ultrathin probes through a 17-gauge brachytherapy template-technique and preliminary results.

OBJECTIVES: To describe a new surgical approach to third-generation cryoablation of the prostate and present our preliminary results. METHODS: The technique is detailed and demonstrated in a Web-based video- clip tutorial. Ninety-two men underwent prostate cryoablation (71 primary ablations, 19 salvage procedures, and 2 repeated cryoablations), using direct transperineal placement of ultrathin probes through a 17-gauge brachytherapy template. RESULTS: No fistulous or major complications were observed. Eight patients (8.3%) had minor complications. In 36 patients, the follow-up period was long enough to permit nadir prostate-specific antigen (PSA) evaluation. In 31 (86%), the nadir PSA was 0.5 ng/mL or less. In 5 patients, the nadir PSA was greater than 0.5 ng/mL. The workup revealed systemic failure in 3 patients and inadequate eradication of the prostate gland in 2 patients. In 18 (86%) of 21 androgen-ablation-naive patients, the nadir PSA was 0.5 ng/mL or less. Nine (43%) had an undetectable nadir PSA and 3 had a nadir PSA of greater than 0.5 ng/mL. CONCLUSIONS: A modified, less-invasive approach to cryoablation of the prostate is presented. The preliminary results do not show an increased rate of complications compared with other published series. The clinical outcome data are preliminary. Longer follow-up data are required to draw conclusions concerning efficacy.

Clinical experience with open renal cryoablation.

OBJECTIVES: To evaluate the safety and efficacy of open renal cryoablation of small solid renal masses, since the delivery of freezing temperatures has been shown to effectively ablate solid neoplasms of the liver, uterus, and prostate. METHODS: A total of 29 patients were treated with open renal cryoablation since December 1996 and followed up to evaluate the treatment safety and initial radiographic response. RESULTS: The median preoperative lesion size was 2.2 cm, with 22 solid renal masses and 7 complex renal lesions. Five serious adverse events occurred in 5 patients, with only one event directly related to the procedure. One patient experienced a biopsy-proven local recurrence, and 91.3% of patients (median follow-up 16 months) demonstrated a complete radiographic response with only a residual scar or small, nonenhancing cyst. CONCLUSIONS: Open renal cryoablation appears to be a safe technique for the in situ destruction of solid or complex renal masses. However, inadequate freezing of renal cell carcinoma may result in local disease persistence. The expected slow growth rate of small renal cancers necessitates prolonged radiologic follow-up. Continued clinical research is required before renal cryoablation can be considered an acceptable curative treatment for renal cancer.

The relationship between quality and costs: factors that affect the hospital costs of radical prostatectomy.

The present study seeks to establish a relationship between the quality of a surgical procedure and the subsequent hospital costs for that procedure by investigating the influence of both patient and peri-operative factors on the hospital costs of radical prostatectomy. All men who underwent radical prostatectomy at one institution during an 18-month period were included in this study. Clinical information was obtained from medical records and cost information was obtained from hospital billing data. The medical record was also used to determine peri-operative information such as operating room time, anesthesia time, surgical time, blood loss and units of packed red blood cells transfused. The correlation between costs and both clinical and peri-operative factors were determined using the Pearson correlation co-efficient. One hundred and four men underwent radical prostatectomy at our institution during the time period studied. Mean age of these patients was 60.2 y and mean length of stay for these patients was 3.4 days with a range of 2-10 days. Mean total hospital costs for this cohort was $5305 with a range of $2851-$10 358. Significant correlations with total hospital costs included operating room time, surgical time, estimated blood loss and blood transfused. Patient factors such as age, ASA class, co-morbidities and smoking history were not correlated with total hospital costs. The present study demonstrates that factors at least partially controlled by the surgeon such as surgical time and units of blood transfused directly influence the total hospital costs of radical prostatectomy, while patient factors such as age and the presence of co-morbidities had no significant correlation with total hospital costs. These findings demonstrate that surgeons can impact health care costs by providing high quality care and begins to establish a relationship between high quality care and low cost care.Prostate Cancer and Prostatic Diseases (2001) 4, 213-216.

Fine-needle aspiration cytology of low-grade fibromyxoid sarcoma of the renal capsule (capsuloma).

We report on the fine-needle aspiration (FNA) findings of a low-grade fibromyxoid sarcoma arising from the renal capsule in a 70-yr-old male. Cytologic examination revealed a spindle-cell and myxoid lesion characterized by microtissue fragments of delicate spindle-shaped cells and thin-walled capillary-type channels enmeshed in metachromatically staining myxoid material, best appreciated in Diff-Quik-stained smears. The spindle cells had slightly elongated, bland, oval to tapered nuclei. Based on the FNA diagnosis, the renal mass was resected, which revealed a hypocellular to moderately cellular, spindle-shaped neoplasm showing alternating hypercellular fibrous foci with hypocellular myxoid areas arranged in a swirling growth pattern, characteristic of low-grade fibromyxoid sarcoma. We believe that this is the first report of a low-grade fibromyxoid sarcoma arising in the renal capsule (capsuloma), as well as the first capsuloma diagnosed by FNA biopsy. Differential diagnoses of other sarcomas arising from the kidney and nearby retroperitoneal region are discussed, as well as other entities that might enter into the differential diagnosis of this low-grade sarcoma.

Counseling patients about cryotherapy for prostate cancer in the information age.

Patients diagnosed with prostate cancer who elect to pursue active treatment of their disease must choose among the many available treatment alternatives. Several treatment options now exist for similar stage disease (clinical T1-3N0M0), including radical prostatectomy, external beam radiotherapy, prostate brachytherapy, cryosurgical ablation of the prostate (CSAP), and various combination therapies. This article focuses principally on the authors' philosophy regarding the role of CSAP in the treatment of clinically localized prostate cancer and is written to aid patients in their treatment decision. There is limited information on CSAP in the standard resources, such as the Internet and books frequently used by patients to make their treatment decisions. This article can serve as a resource on the evolution, results, and complications of CSAP that are reported. Cryosurgical ablation of the prostate has a role in the primary treatment of men with high risk, clinically localized prostate cancer (defined as prostate-specific antigen >10, Gleason score > or =7, or clinical stage > or =cT2B). Cryosurgical ablation of the prostate (occasionally followed by external beam radiotherapy) appears to offer improved rates of cancer control over other types of single or combination therapies for this high risk prostate cancer, and is associated with an acceptable side effect profile. Cryosurgical ablation of the prostate should also be the treatment of choice for men with recurrent local disease after external beam radiotherapy.

A comparison of complications between ultrasound-guided prostate brachytherapy and open prostate brachytherapy.

PURPOSE: Prostate brachytherapy has reemerged during the 1990s as a treatment for clinically localized prostate cancer. The renewed popularity of prostate brachytherapy is largely due to the use of transrectal ultrasound of the prostate, which allows for more accurate isotope placement within the prostate when compared to the open approach. The present study investigates whether this improved cancer control is at the expense of increased morbidity by comparing the morbidity after transrectal ultrasound-guided prostate brachytherapy to the morbidity after prostate brachytherapy performed via an open approach. METHODS AND MATERIALS: All men in the Medicare population who underwent prostate brachytherapy in the year 1991 were identified. These men were further stratified into those men who underwent prostate brachytherapy via an open approach and the men who underwent prostate brachytherapy with ultrasound guidance. All subsequent inpatient, outpatient, and physician (Part B) Medicare claims for these men from the years 1991-1993 were then analyzed to determine outcomes. RESULTS: In the year 1991, 2124 men in the Medicare population underwent prostate brachytherapy. An open approach was used in 715 men (33.7%), and ultrasound guidance was used in 1409 men (66.3%). Mean age for both cohorts was 73.7 years with a range of 50.7-92.8 years for the ultrasound group and 60.6-92. 1 years for the open group. A surgical procedure for the relief of bladder outlet obstruction was performed in 122 men (8.6%) in the ultrasound group and in 54 men (7.6%) in the open group. An artificial urinary sphincter was placed in 2 men (0.14%) in the ultrasound group and in 2 men (0.28%) in the open group. A penile prosthesis was implanted in 10 men (0.71%) in the ultrasound group and in 4 men (0.56%) in the open group. A diagnosis code for urinary incontinence was carried by 95 men (6.7%) in the ultrasound group and by 45 men (6.3%) in the open group. A diagnosis code for erectile dysfunction was carried by 90 men (6.3%) in the ultrasound group and by 64 men (9.0%) in the open group. CONCLUSION: Prostate brachytherapy performed with ultrasound guidance does not appear to increase significantly complications resulting from the procedure. Both techniques appear to offer similar rates of procedures performed to correct urinary incontinence, bladder outlet obstruction and erectile dysfunction. The limitations of claim information in determining patient outcomes, however, must be considered when evaluating this data.

Complications after radical retropubic prostatectomy in the medicare population.

OBJECTIVES: Radical prostatectomy is the standard of care for the treatment of clinically localized prostate cancer in the appropriate patient. However, the morbidity associated with this procedure remains controversial, since complications from centers of excellence are low but nationwide surveys have reported a much higher risk of complications. This study reports the complication rates after radical retropubic prostatectomy (RRP) for men in the Medicare population. METHODS: All men in the Medicare population who underwent RRP in 1991 were identified. All inpatient, outpatient, and physician (Part B) Medicare claims for these men for 1991 to 1993 were then analyzed to determine outcomes. Procedures performed for complications resulting from RRP were recorded, as were the diagnosis codes that may have heralded a complication after RRP. RESULTS: In 1991, 25,651 men in the Medicare population underwent RRP. The mean age of these men was 70.5 years. Procedures for the relief of bladder outlet obstruction or urethral strictures after RRP occurred in 19.5% of these men. A penile prosthesis was implanted in 718 men (2.8%) after prostatectomy, and 593 men (2.3%) had an artificial urinary sphincter placed after prostatectomy. A diagnosis of urinary incontinence was reported in 5573 men (21.7%) after radical prostatectomy, but only 2025 of these men (7.9%) continued to carry this diagnosis more than 1 year after prostatectomy. A diagnosis of erectile dysfunction was reported in 5510 men (21.5%) after radical prostatectomy, but only 3276 of these men (12.8%) continued to carry this diagnosis more than 1 year after surgery. CONCLUSIONS: A review of a large, nationwide, heterogenous cohort of men revealed a morbidity rate that is slightly higher than that reported by major centers that perform large numbers of radical retropubic prostatectomies but is lower than complication rates obtained by patient surveys. The limitations of claim information in determining patient outcomes, however, must be considered when evaluating these data.

Complications after prostate brachytherapy in the Medicare population.

OBJECTIVES: Prostate brachytherapy is gaining in popularity among patients and physicians for the treatment of clinically localized prostate cancer. Although several major centers have published their results and morbidity data, nationwide data concerning complications have not been available. This study reports complications after prostate brachytherapy for men in the Medicare population. METHODS: All men in the Medicare population who underwent prostate brachytherapy in 1991 were identified. All inpatient, outpatient, and physician (Part B) Medicare claims for these men from 1991 to 1993 were then analyzed to determine outcomes. RESULTS: In 1991, 2124 men in the Medicare population underwent prostate brachytherapy. A total of 176 men (8.3%) underwent a surgical procedure for bladder outlet obstruction during the follow-up period, including transurethral resection of the prostate in 141 men. Seven men (0.3%) underwent a colostomy for complications secondary to radiation, and 4 men (0.2%) had an artificial urinary sphincter placed after prostate brachytherapy. Penile prostheses were placed in 14 men (0.6%) in the first 24 to 36 months after prostate brachytherapy. A diagnosis of urinary incontinence was carried by 140 men (6.6%) after the procedure; 179 men (8.4%) carried a diagnosis of erectile dysfunction after their procedure. A diagnosis consistent with rectal injury secondary to radiation appeared in 116 men (5.5%) after prostate brachytherapy. CONCLUSIONS: Prostate brachytherapy is being promoted as an effective treatment option for clinically localized prostate cancer that offers a low risk of complications. The low rate of urinary incontinence, bladder outlet obstruction, and erectile dysfunction was confirmed by analyzing a nationwide cohort of men. Rectal complications were also consistent with those described in published studies. The limitations of claim information in determining patient outcomes, however, must be kept in mind when evaluating these data.

Cryosurgery for prostate cancer: new technology and indications.

Patients diagnosed with prostate cancer who elect to pursue active treatment of their disease must choose among the many available treatment alternatives. Several treatment options now exist for similar-stage disease (clinical T1-3N0M0), including radical prostatectomy, external beam radiation, prostate brachytherapy (PB), and cryosurgical ablation of the prostate (CSAP). This article reviews the current role of CSAP in the treatment of clinically localized prostate cancer. CSAP has a role in the primary treatment of men with high-risk, clinically localized prostate cancer (defined as PSA >10, Gleason score >or=7, or clinical stage >or= cT2B). CSAP (occasionally followed by external beam radiotherapy) appears to offer improved rates of cancer control over other types of single or combination therapies for this high-risk prostate cancer, and it is associated with an acceptable side-effect profile. CSAP should also be the treatment of choice for men with recurrent local disease who have undergone external beam radiotherapy or PB.

Activity of prefrontal neurons during location and color delayed matching tasks.

Many cells in prefrontal cortex show enhanced activity prior to movement onset in delayed or memory-guided saccade tasks. This activity is a possible neural correlate of spatial attention and working memory. The goal of this study was to determine whether delay activity is evoked when non-spatial cues such as color are used to guide saccades. Monkeys were trained on a saccade target selection task in which they were cued for either the location or color of the rewarded target. When the location of the target was specified explicitly, many cells showed visual responses and delay activity that were spatially selective. Color selective visual responses or delay activity were both rare and weak. However, for many cells, spatially selective delay activity could be evoked when color was used to specify the location of the target. These results indicate that color is capable of eliciting spatially selective activity from cells that have no overt color selectivity.

Comparison of the hospital costs for radical prostatectomy and cryosurgical ablation of the prostate.

OBJECTIVES: To compare the hospital costs of radical prostatectomy (RP) and cryosurgical ablation of the prostate (CSAP). METHODS: All patients who underwent either RP or CSAP at Allegheny General Hospital during an 18-month period beginning in January 1995 were included in this study. Hospital costs were generated for each case, and a chart review was undertaken for each patient. Costs were obtained from the hospital accounting office and divided into 11 categories, including total costs. Pretreatment grade, clinical stage, and prostate-specific antigen level were obtained from the patient's chart. Noncost information such as length of stay, number of operating room units charged, and patient age were also obtained from the hospital record. RESULTS: Sixty-seven men underwent RP and 114 men underwent CSAP during the study period. Average hospital costs were $4150 for men undergoing CSAP and $5660 for men undergoing RP, a difference of 27.2% (P < 0.001). The difference in hospital costs was almost completely explained by the difference in room costs ($682 for CSAP and $2348 for RP). Length of stay was 1.1 days for CSAP and 3.5 days for RP. Average operating room costs were higher for CSAP ($2309) than for RP ($ 1326). CONCLUSIONS: As costs become an ever more critical factor in healthcare, the costs of various treatment options for clinically localized prostate cancer will become as important as clinical outcomes in deciding appropriate treatment. From a strictly financial perspective, CSAP is a viable treatment option for clinically localized prostate cancer.

Intraoperative ultrasonographically guided cryoablation of renal masses: initial experience.

The purpose of this study was to evaluate the feasibility of intraoperative ultrasonography to guide cryoablation of renal masses. Renal cryoablation was performed on six patients with solid renal tumors. Under ultrasonographic guidance, cryoprobes measuring 3 mm in diameter were placed into the renal tumor parenchyma or into surrounding normal parenchyma. Intraoperative ultrasonography accurately delineated tumor size, cryoprobe placement, and depth of freezing. An echogenic interface was generated by the marked impedance differences at the junction of the normal renal parenchyma and frozen tissue. In addition, intraoperative ultrasonography identified a total of nine additional lesions in three patients that were not detected by preoperative imaging. These lesions also were treated cryosurgically during the same operation. There were no deaths. The patients have been followed with clinical and laboratory assessments as well as with MR imaging or CT scanning, and all have remained tumor free 3 to 22 months postoperatively. Ultrasonographically guided renal cryoablation is a feasible technique for treating malignant renal tumors while preserving renal parenchyma. Long-term follow-up studies in a larger series of patients are required to determine the true efficacy and safety of this procedure.

Histological presence of viable prostatic glands on routine biopsy following cryosurgical ablation of the prostate.

PURPOSE: Cryosurgical ablation of the prostate has recently received much attention as a therapeutic alternative for the treatment of localized prostatic adenocarcinoma. Biopsies after treatment reveal a variety of dysplastic changes as well as unaltered prostatic glandular epithelial elements. Prostate specific antigen (PSA) remains undetectable in the majority of men. However, in some PSA increases without demonstrable local recurrence. MATERIALS AND METHODS: A total of 383 patients underwent 447 procedures between June 1990 and January 1994. Of 358 biopsies performed at our institution, 317 (2,075 cores) were available for review. Each core was examined for unaltered prostatic glandular epithelial elements and then scored for the percentage of epithelial glandular involvement according to a scale of: 0-no, 0.5-less than 10%, 1-10 to 25%, 2-25 to 50%, 3-50 to 75% and 4-76 to 100% unaltered prostatic glandular epithelial elements. RESULTS: Of 317 biopsies 158 (49.8%) contained no unaltered prostatic glandular epithelial elements, while 185 (58.3%) and 206 (65%) had 1 core containing 10% and 10 to 25%, respectively, of such elements. Of 262 cases (82.6%) with a mean of 10% unaltered prostatic glandular epithelial elements per core 22 (8.4%) were positive for residual carcinoma. Among 55 cases with more normal epithelium per core 24 (43.6%) were positive for residual carcinoma. Patients with a positive biopsy had a median PSA of 2.02 ng./ml. (average gland/core score 0.54). Median PSA for men with negative biopsies was 0.2 ng./ml. (gland/core score 0.124). CONCLUSIONS: Cryosurgical ablation of the prostate has the ability to ablate prostatic tissue completely, thus rendering it free of glandular elements as determined by biopsy. Increasing PSA can indicate residual glandular elements. Increases in unaltered prostatic glandular epithelial elements with time are not paralleled by increased rates of local disease recurrence. undetectable serum PSA has a low risk of residual unaltered prostatic glandular epithelial elements and localized carcinoma. Results as measured by unaltered prostatic glandular epithelial elements and PSA improve with the surgical experience.

Magnetic resonance imaging of normal meningeal enhancement at 1.5 T.

RATIONALE AND OBJECTIVES: We examined patterns of intracranial meningeal enhancement on gadolinium chelate contrast media-enhanced 1.5-T spin-echo magnetic resonance (MR) imaging and developed criteria that might be useful for distinguishing between normal and abnormal meningeal enhancement. METHODS: The convexity, falx cerebri, tentorium cerebelli, and suprasellar cistern regions of 204 patients were prospectively evaluated for contrast enhancement with a grading system ranging from 0 (no enhancement) to 5 (diffuse, irregular, thickened enhancement). Meningeal findings were correlated with other MR abnormalities and pertinent clinical histories that have been associated previously with meningeal enhancement. RESULTS: Short-segment convexity meningeal enhancement was commonly seen and most likely represents intravascular contrast material in normal meningeal vessels. Such enhancement did not correlate with the presence of other MR abnormalities. Long-segment (> 3 cm) or diffuse convexity meningeal enhancement did correlate with other significant MR abnormalities and pertinent clinical history. Fine linear falcine and tentorial meningeal enhancement, as an isolated finding, did not correlate with other MR or clinical abnormalities. The suprasellar cistern and ventricular walls were rarely enhanced. CONCLUSION: Short-segment convexity meningeal contrast enhancement is a normal finding representing normal vascular structures. More extensive convexity meningeal enhancement is abnormal and should prompt careful examination of the remainder of an MR image as well as the patient's clinical history for an etiology of the enhancement.

Percutaneous, transperineal cryosurgery of the prostate as salvage therapy for post radiation recurrence of adenocarcinoma.

BACKGROUND: Surgical techniques utilizing the application of very low temperatures to malignant tissues have been used increasingly in recent years in the minimally invasive treatment of prostate cancer. An area of potential application appears to be in the management of radiation resistant prostate cancer. METHODS: This study represents a retrospective chart review of 33 patients undergoing cryosurgical ablation of the prostate (CSAP) according to a protocol designed by an institutional review board at a single institution for the treatment of radiation resistant prostate cancer. Radiation resistance was defined as a positive prostate needle biopsy and rising prostate specific antigen (PSA). Treatment effect was assessed by serial post treatment PSA determinations and extensive systematic post treatment prostate needle biopsies. RESULTS: Of the 33 patients analyzed, 24 converted to an all negative biopsy status after one CSAP treatment. Repeat treatment converted two additional patients to a biopsy negative status. CSAP appeared to lower PSA dramatically in most patients. One year after treatment, of 10 patients not on androgen deprivation therapy, 3 maintained a PSA of < 0.4 ng/mL and those patients with androgen deprivation therapy maintained a PSA of < 4.0 ng/mL. The most frequent complications included sloughing syndrome (15.4%) and incontinence (10.3%). CONCLUSIONS: CSAP appears to eliminate biopsy detectable prostate tumor effectively in the majority of cases in the salvage setting following radiation therapy. A significant discrepancy exists, however, between the biopsy "cure" rate and the biochemical "cure" rate, even in the short term. There is a suggestion that early detection of radiation failure may improve results of this salvage therapy.

Cryosurgical ablation of the prostate: two-year prostate-specific antigen and biopsy results.

OBJECTIVES: Percutaneous cryosurgical ablation of the prostate (CSAP) was performed on patients with localized or locally advanced adenocarcinoma of the prostate. To assess local disease control, post-treatment biopsy and serum prostate-specific antigen (PSA) levels were obtained at 3 and 24 months post-treatment. METHODS: From June 1990 through May 1994, CSAP was performed 448 times on 383 patients under Institutional Review Board protocols. A urethral warming catheter was used for all procedures. A total of 239 patients were followed for a minimum of 21 months after treatment. None of this group had received prior local treatment. The group consisted of patients who were newly diagnosed and treated solely with cryotherapy (virgin); the remainder had been on androgen deprivation therapy (ADT) prior to CSAP. RESULTS: Biopsies were obtained from 114 patients at 21 months or more after treatment. In the virgin group, 79% had a negative biopsy after one or more treatments, and 88% of the ADT group are negative after one or more treatments. Overall, 69% had a negative biopsy after one treatment and 82% had a negative biopsy following one or more CSAP treatments. Of a group of 163 patients, PSA data were evaluable at 21 months or more after treatment. In the virgin group, 60% had a PSA 0.4 ng/mL or less, and 77% had a PSA 1.0 ng/mL or less. In the ADT group, 40% had a PSA 0.4 ng/mL or less, and 69% had a PSA value of 1.0 ng/m Lor less. Complications were minimal, the most common one being urethral tissue sloughing, which occurred in 10% of patients. CONCLUSIONS: CSAP appears to be effective in obtaining local control as measured by biopsy and PSA 21 months or more post-treatment. When retrospectively comparing our results with recently published radiotherapy series, CSAP was more effective in obtaining nadir PSA values 1.0 ng/mL or less and negative biopsies at 21 months or more after treatment.