Identifying candidates for active surveillance: an evaluation of the repeat biopsy strategy for men with favorable risk prostate cancer.

PURPOSE: Active surveillance is increasingly recommended to reduce overtreatment in men with favorable risk prostate cancer. A repeat confirmatory biopsy has become the standard recommendation for these men to increase the precision of this risk attribution. We investigate the usefulness of this approach by comparing the current practice standard, repeat transrectal ultrasound biopsy, with template prostate mapping. MATERIALS AND METHODS: A total of 124 men who were attributed a favorable risk prostate cancer status based on transrectal ultrasound guided biopsy and who were considering a policy of active surveillance underwent combined transrectal ultrasound biopsy and template prostate mapping as a confirmatory strategy. Maximum Gleason grade and disease burden were compared between the 2 confirmatory tests. RESULTS: Depending on the definition used between 8% and 22% of men had prostate cancer reclassified as clinically important by repeat transrectal ultrasound biopsy whereas template guided prostate mapping reclassified the disease in 41% to 85% of the men. Repeat transrectal ultrasound biopsy failed to detect up to 80% of clinically important cancers detected by the reference standard. The sensitivity of repeat transrectal ultrasound biopsy to identify clinically important disease varied from 9% to 24% with the negative predictive value ranging from 23% to 60%. CONCLUSIONS: When applied to a population of men initially deemed to have favorable risk prostate cancer, transrectal ultrasound biopsy will miss a large proportion of clinically important cancers compared to template guided prostate mapping. The usefulness of repeat transrectal ultrasound biopsy in ruling out clinically important prostate cancer needs to be reconsidered.

Plasmacytoid urothelial carcinoma of the bladder. A case report and the first description of urinary cytology.

BACKGROUND: Plasmacytoid carcinomas are rare variants, and there are only a few reported examples of plasmacytoid carcinoma of the urinary bladder in the English-language literature. We now report another such case and the first in which there was examination of urinary cytology. CASE: A 79-year-old, Caucasian woman who presented with gross hematuria following a revascularization procedure on the right arm was found to have an extensive, diffuse carcinoma of the bladder. On biopsy, there were single, round and polygonal tumor cells with a striking plasmacytoid appearance infiltrating diffusely throughout the edematous lamina propria. Immunocytochemical stains confirmed an epithelial classification, and carcinoma in situ was demonstrated in the contiguous urothelium. Voided urine cytology before and after cystoscopy and biopsy demonstrated large, dyshesive tumor cells with plasmacytoid features. CONCLUSION: A case of plasmacytoid variant of urothelial carcinoma of the bladder is reported, with the first description of its urinary cytology.

Signet-ring follicular adenoma of the thyroid diagnosed by fine needle aspiration. Report of a case with cytologic description.

BACKGROUND: Follicular cells of the thyroid may undergo squamous, oncocytic or clear cell metaplastic changes. Of these, the clear cell change with signet-ring formation is the most unusual, and follicular adenoma of the thyroid with signet-ring formation is extremely rare. We describe for the first time the cytologic features of a clear cell adenoma of the thyroid obtained by fine needle aspiration (FNA). CASE: A 48-year-old woman in a euthyroid state presented with a 2-cm, right-sided thyroid nodule. Smears obtained by FNA of the nodule revealed clusters of large signet-ring cells in a bloody background. The signet-ring cells were round to oval, with large cytoplasmic vacuoles and hyperchromatic, eccentric nuclei. Colloid in the background was very scanty. Histologic examination of the right hemithyroidectomy specimen revealed a signet-ring follicular adenoma. CONCLUSION: Lack of familiarity with signet-ring cell adenoma of the thyroid could lead to an erroneous diagnosis of metastatic signet-ring cell carcinoma.

Simultaneous cytomegalovirus infection and Kaposi's sarcoma of the thyroid diagnosed by fine needle aspiration in an AIDS patient. A case report and first cytologic description of the two entities occurring together.

BACKGROUND: Cytomegalovirus (CMV) infection and Kaposi's sarcoma (KS) are common in AIDS patients but rarely involve the thyroid, and coexistence of these two entities in that organ has not yet been described before. CASE: A 41-year-old female AIDS patient presented with a 2 x 1-cm, well-demarcated, rubbery mass in the right side of the thyroid. On fine needle aspiration (FNA), spindle cells were retrieved singly or in small, loose clusters; they had bland, fusiform to cigar-shaped nuclei; inconspicuous nucleoli; delicate cytoplasmic vacuoles; cytoplasmic hyaline drops; and hemosiderin granules. A single endothelial cell showed an enlarged nucleus with a basophilic intranuclear inclusion and periinclusional halo. CONCLUSION: This is the first reported case of an AIDS patient with KS and CMV infection simultaneously involving the thyroid diagnosed by FNA.

Randomized controlled trials of the efficacy of lung cancer screening by sputum cytology revisited: a combined mortality analysis from the Johns Hopkins Lung Project and the Memorial Sloan-Kettering Lung Study.

BACKGROUND: : Two randomized controlled trials of lung cancer screening initiated in the 1970s, the Johns Hopkins Lung Project and the Memorial Sloan-Kettering Lung Study, compared 1 arm that received annual chest X-ray and 4-monthly sputum cytology (dual-screen) to a second arm that received annual chest X-ray only. Previous publications from these trials reported similar lung cancer mortality between the 2 groups. However, these findings were based on incomplete follow-up, and each trial on its own was underpowered to detect a modest mortality benefit. METHODS: : The authors estimated the efficacy of lung cancer screening with sputum cytology in an intention-to-screen analysis of lung cancer mortality, using combined data from these trials (n = 20,426). RESULTS: : Over (1/2) of squamous cell lung cancers diagnosed in the dual-screen group were identified by cytology; these cancers tended to be more localized than squamous cancers diagnosed in the X-ray only arm. After 9 years of follow-up, lung cancer mortality was slightly lower in the dual-screen than in the X-ray only arm (rate ratio [RR], 0.88; 95% confidence interval [CI], 0.74-1.05). Reductions were seen for squamous cell cancer deaths (RR, 0.79; 95% CI, 0.54-1.14) and in the heaviest smokers (RR, 0.81; 95% CI, 0.67-1.00). There were also fewer deaths from large cell carcinoma in the dual-screen group, although the reason for this is unclear. CONCLUSIONS: : These data are suggestive of a modest benefit of sputum cytology screening, although we cannot rule out chance as an explanation for these findings. Cancer 2009. (c) 2009 American Cancer Society.

Appropriate patient selection in the focal treatment of prostate cancer: the role of transperineal 3-dimensional pathologic mapping of the prostate--a 4-year experience.

This study was undertaken to evaluate the usefulness of transperineal mapping biopsy of the prostate as a staging procedure in the appropriate selection of patients for treatment with focal cryoablation. Between October 2001 and January 2006, a total of 80 patients underwent extensive template-guided transperineal pathologic mapping of the prostate (3-DPM), in conjunction with repeat transrectal ultrasound (TRUS)-guided biopsies. Before 3-DPM was performed, the following clinical variables were recorded: age, prostate-specific antigen (PSA), percent free PSA, total prostate volume, transition zone volume, Gleason score, TNM stage, number of positive cores, and maximum percent of positive cores. Results of 3-DPM were compared with those of TRUS-guided biopsies to determine patient suitability for focal cryoablation; this served as the study end point. Of 80 study patients, 43 (54%) were deemed unsuitable for focal cryoablation. When compared with 3-DPM in assessing patient suitability for focal cryoablation repeat TRUS-guided biopsies yielded a false-negative rate of 47%, a sensitivity of 54%, and a negative predictive value of 49%. None of the pre-3-DPM variables correlated significantly with patient suitability for focal ablation. Treatment selected by the 80 study patients included total gland cryoablation (30%), expectant management (23%), radical prostatectomy (18%), focal cryoablation (11%), external irradiation (10%), brachytherapy (6%), and combined external irradiation and brachytherapy (1%); 1% were undecided about treatment selection. In this study, we demonstrated that 3-DPM (1) effectively excluded patients with clinically significant unsuspected cancer outside the area destined to be ablated, (2) appeared to do so more effectively than repeat TRUS-guided biopsies, and (3) was able to precisely locate the site of the cancer to be selectively ablated.

Rapid Analysis of Normal and Abnormal Cell Types in Human Semen and Testis Biopsies by Flow Cytometry 12.

A simple, rapid procedure is described that quantitates RNA content and DNA content/chromatin condensation for each of many possible cell types and differentiation levels of the cells present in human semen. A fresh semen sample (1-6 hr postemission) or frozen sample (allowing samples to be accumulated and sent to a laboratory) is treated with a detergent solution, stained with acridine orange (AO), and measured by flow cytometry (FCM); approximately 10 minutes are required to measure 5,000 cells per sample and analyze the data with computer assistance. The following can be learned from a single measurement: a) the percentage of each cell type in semen including, i) mature sperm, ii) immature sperm precursor cells, representing all stages of development from spermatogonia to mature sperm, iii) somatic cells, e.g., leukocytes; b) normality/abnormality of sperm nuclear chromatin condensation. These measurements can be correlated with cell types in testis biopsies identified by two-parameter FCM measurements (RNA versus DNA) using AO as the fluorescent probe.

An approach to diagnosis of T-cell lymphoproliferative disorders by flow cytometry.

T-cell lymphoproliferative disorders are among the most challenging diagnoses in hematopathology. Unlike the more common B-cell disorders, in which clonality is often readily discernible by surface immunoglobulin light chain restriction, there is no specific immunophenotypic signature that is diagnostic of a clonal T-cell population. Immunophenotypic criteria that are helpful in the diagnosis of T-cell neoplasms include T-cell subset antigen restriction, anomalous T-cell subset antigen expression, deletion or diminution of one of the pan T-cell antigens, a precursor T-cell phenotype, and expression of additional markers (e.g., CD30, CD20, major myeloid antigens, and TCRgammadelta). Analysis of the inherent forward and orthogonal light scatter properties of the cell can also provide important diagnostic clues. None of these features is 100% specific, however, for aberrant expression of pan-T antigens may be seen in viral infections, B-cell malignancies, or in reactive changes following administration of certain medications. An increased CD4:CD8 ratio is often observed in Hodgkin's lymphoma. Based on the analysis of 87 neoplastic and 80 control cases, we conclude that flow cytometric features that are most suspicious for malignancy include the loss or markedly dim expression of CD45; complete loss of one or more pan-T antigens; diminished expression of more than two pan-T antigens in conjunction with altered light scatter properties; and CD4/CD8 dual-positive or dual-negative expression (except thymic lesions).