Percutaneous core biopsy of small renal mass lesions: a diagnostic tool to better stratify patients for surgical intervention.

OBJECTIVES: To further validate the safety and diagnostic accuracy of percutaneous core biopsy in small renal masses ([SRMs]≤4 cm) in response to the rising prevalence of renal 'incidentalomas'. To determine the value of percutaneous core biopsy in its ability to influence the choice of intervention or surveillance for the management of SRMs. PATIENTS AND METHODS: We collected data on the incidence of benign, malignant and non-diagnostic samples from 268 SRM (clinical T1a) biopsies performed at our institution between 1998 and 2009. The diagnostic accuracy of biopsy in small renal lesions was examined in cases proceeding to nephrectomy. Follow-up on the remaining non-surgical cases was performed. RESULTS: SRMs (≤4 cm, clinical T1a) constituted 59% of all renal lesions diagnosed; 80% of these biopsies were diagnostic and 20% were non-diagnostic. Of the diagnostic samples, 74% were malignant and 26% were benign. Thirty-three percent (17 of the initial 52) non-diagnostic samples underwent re-biopsy, with 94% yielding a histological diagnosis on repeat sampling. Fifty-eight percent of our diagnostic masses underwent nephrectomy, returning a renal biopsy accuracy rate of 100% for identifying lesions as benign or malignant. Of the 98 observed masses, 49% were benign, 28% malignant and 23% were non-diagnostic. In 63% of these cases, size remained stable in the follow-up period. CONCLUSIONS: Percutaneous core biopsy continues to provide an accurate and safe tool for preoperative tissue diagnosis of SRMs and should be offered to patients before considering surgical intervention. With regard to both benign and malignant T1a renal lesions, in select patient groups, those electing to undergo observation may expect favourable short- to medium-term outcomes.

A new preoperative nomogram to predict minimal prostate cancer: accuracy and error rates compared to other tools to select patients for active surveillance.

PURPOSE: We designed and fully evaluated the performance of a nomogram to identify patients with prostate cancer who may be suitable for active surveillance. MATERIALS AND METHODS: We developed a nomogram to predict the probability of minimal prostate cancer (total tumor volume less than 0.5 cc, organ confined disease and no Gleason pattern 4 or 5) using preoperative data on 2,525 Australian patients who underwent radical prostatectomy. Accuracy and error rates at multiple probability cutoffs were compared with those of contemporary Epstein criteria and the Prostate Cancer Research International: Active Surveillance trial inclusion criteria when applied to these patients. High risk disease was defined as 1 or more adverse characteristics (including positive surgical margins, seminal vesicle invasion, extracapsular extension, 50% or greater Gleason pattern 4/5 and/or tumor volume 4.0 cc or greater) at radical prostatectomy. RESULTS: Minimal cancer was confirmed in 152 men (6.0%) at prostatectomy. The bootstrap corrected predictive accuracy of our nomogram was 93.3% vs 89.1% and 91.0% for Prostate Cancer Research International: Active Surveillance and Epstein criteria, respectively. For men with a nomogram derived minimal cancer probability of 0% to 4.9%, 5.0% to 19.9%, 20.0% to 34.9%, 35.0% to 49.9% and 50.0% to 71.0% the rate of high risk disease was 70.8%, 37.8%, 22.4%, 9.0% and 3.8%, respectively. In contrast, the rate of high risk disease for men who met Prostate Cancer Research International: Active Surveillance and Epstein criteria were 17.1% and 13.9%, respectively. CONCLUSIONS: A detailed breakdown of the expected rates of false-positive results and high risk disease associated with the nomogram derived probability of minimal cancer would provide more complete information to clinicians and patients on which to base therapeutic clinical decisions for presumed early stage prostate cancer.

A post-radical-prostatectomy nomogram incorporating new pathological variables and interaction terms for improved prognosis.

OBJECTIVE: To evaluate new variables in prostate pathology reporting including, the per cent of Gleason patterns 4 and/or 5 (% 4/5), presence or absence of intraductal carcinoma of the prostate (IDCP), tumour volume and the prostatic zone of tumour origin as predictors of post-radical-prostatectomy (RP) biochemical recurrence (BCR). To develop an optimal postoperative nomogram for patients with prostate cancer. PATIENTS AND METHODS: Our study cohort was 1939 eligible patients from the Abbott West Australian Prostatectomy Database. Multivariate Cox proportional hazard regression models were developed to predict BCR which was defined as prostate-specific antigen (PSA) ≥ 0.2 ng/mL. Our models and the 2009 Kattan postoperative nomogram were compared in terms of discrimination and calibration, with internal validation of our final model performed using bootstrapping methods. Our final model is presented as a nomogram. RESULTS: The Kattan nomogram was accurate in discriminating our patients according to risk (concordance index: 0.791) but calibration analysis indicated underestimation of patient risk, particularly for high-risk disease. Our nomogram incorporates % 4/5, IDCP and prostate weight plus interaction terms between % 4/5, positive surgical margins and extracapsular extension, giving improved predictive accuracy (concordance index: 0.828) and calibration. CONCLUSIONS: Nomograms that predict risk of BCR defined as PSA ≥ 0.4 ng/mL may not be optimal for patient cohorts where BCR is defined as PSA ≥ 0.2 ng/mL. If our findings are validated in other populations, current post-RP nomograms may be improved to a modest degree by incorporating the new variables prostate weight, IDCP and % 4/5, and by considering interactions between predictive variables.

Cervical screening in Canadian First Nation Cree women.

PURPOSE: Attitudes and beliefs of First Nation Cree women living in a reserve community were explored to gain insights into how cervical screening could be better utilized. METHOD: Focused ethnography utilizing participant observation and interviews ( n = 8) with participants having experience with cervical screening and/or cancer was conducted. RESULTS: Women did not believe they had adequate information and were resistant to screening because of embarrassment caused by the procedure and fear of cancer, which was viewed as a "death sentence." CONCLUSIONS: Challenges faced by First Nation Cree women when contemplating cervical screening are presented. Nursing sensitivity is needed to strategize access to cervical screening that is culturally appropriate.

Support from a close female relative in labour: the ideal maternity nursing intervention in Thailand.

Childbirth is a significant event in the lives of women and their families. It is a critical time in the human development that transforms women into mothers. Women remember their childbirth for the rest of their lives. Thus, the quality of support that women receive during labour and delivery is important and nurses need to be concerned. Previously, women were delivered at homes; they received emotional support from female relatives. Now women give birth in hospitals; they are separated from their families. Although nurses are adept at providing physical and emotional support, they may have to care for several other women. Nurses sometimes may give support to an individual woman a low priority because they have various clinical responsibilities and paper work. It may create womens' experience emotional loneliness and deal with labour pain and in unfamiliar environment alone. These situations can contribute negative effects on childbirth outcomes. Having a close female relative to support a woman in labour can reduce maternal stress and anxiety and improve childbirth outcomes. The present article provides guidelines for including a close female relative on the labour unit to support a woman during labour and delivery.

The relationship between the use of the partograph and birth outcomes at Korle-Bu teaching hospital.

OBJECTIVE: maternal mortality represents the single greatest health disparity between high and low income countries. This inequity is especially felt in low income countries in sub Saharan Africa and Southeast Asia where 99% of the global burden of maternal death is borne. A goal of MDG 5 is to reduce maternal mortality and have a skilled attendant at every birth by 2015. A critical skill is ongoing intrapartum monitoring of labour progress and maternal/fetal well-being. The WHO partograph was designed to assess these parameters. DESIGN AND SETTING: a retrospective review of charts (n=1,845) retrieved consecutively over a 2 month period in a tertiary teaching hospital in Ghana was conducted to assess the adequacy of partograph use by skilled birth attendants and the timeliness of action taken if the action line was crossed. WHO guidelines were implemented to assess the adequacy of partograph use and how this affected maternal neonatal outcomes. Further, the timeliness and type of action taken if action line was crossed was assessed. FINDINGS: partographs were adequately completed in accordance with WHO guidelines only 25.6% (472) of the time and some data appeared to be entered retrospectively. Partograph use was associated with less maternal blood loss and neonatal injuries. When the action line was crossed (464), timely action was taken only 48.7% of the time and was associated with less assisted delivery and a fewer low Apgar scores and NICU admissions. CONCLUSION: when adequately used and timely interventions taken, the partograph was an effective tool. Feasibility of partograph use requires more scrutiny; particularly identification of minimum frequency for safe monitoring and key variables as well as a better understanding of why skilled attendants have not consistently 'bought in' to partograph use. Frontline workers need access to ongoing and current education and strategically placed algorhythims.

Desquamating apoptotic variant of high-grade prostatic intraepithelial neoplasia: a possible precursor of intraductal prostatic carcinoma.

Various patterns of high-grade prostatic intraepithelial neoplasia have been have been described, many of which show morphologic similarity to patterns of prostatic intraductal carcinoma, which is thought to develop either directly from high-grade prostatic intraepithelial neoplasia or by invasion of existing ducts by Gleason pattern 4 or 5 carcinoma. We document a rare and previously unreported "desquamating apoptotic variant" of high-grade prostatic intraepithelial neoplasia where desquamating cells containing apoptotic nuclear material coalesce in the gland lumens to form basophilic intraluminal masses in up to one third of involved acini. This lesion shares features of both high-grade prostatic intraepithelial neoplasia and prostatic intraductal carcinoma and supports the hypothesis that some forms of prostatic intraductal carcinoma evolve directly from high-grade prostatic intraepithelial neoplasia.