NCI Study: MRI of the Prostate Misses Cancers

About 16% of lesions were missed, and approximately 5% of clinically important prostate cancers (>5 mm, Gleason score > 3+3) were underestimated on MP MRI, according to Baris Turkbey, MD, of the Molecular Imaging Program at the National Cancer Institute in Bethesda, Maryland, and colleagues. Overall, prostate cancer size was underestimated by at least 30% in eight (8%) of 100 patients. Their study was published online October 20 in Radiology.

Source: NCI Study: MRI of the Prostate Misses Cancers

PLOS Medicine: Erectile Dysfunction Severity as a Risk Marker for Cardiovascular Disease Hospitalisation and All-Cause Mortality: A Prospective Cohort Study

What Did the Researchers Do and Find?

The researchers used information from the established 45 and Up Study, a large cohort study that includes 123,775 men aged 45 and over, selected at random from the general population of New South Wales, a large region of Australia. A total of 95,038 men were included in this analysis. The male participants completed a postal questionnaire that included a question on erectile functioning, which allowed the researchers to define erectile dysfunction as none, mild, moderate, or severe. Using information captured in the New South Wales Admitted Patient Data Collection—a complete record of all public and private hospital admissions, including the reasons for admission and the clinical diagnosis—and the government death register, the researchers were able to determine health outcomes of all study participants. They then used a statistical model to estimate hospital admissions for cardiovascular disease events for different levels of erectile dysfunction.

The researchers found that the rates of severe erectile dysfunction among study participants were 2.2% for men aged 45–54 years, 6.8% for men aged 55–64 years, 20.2% for men aged 65–74 years, 50.0% for men aged 75–84 years, and 75.4% for men aged 85 years and over. During the study period, the researchers recorded 7,855 hospital admissions related to cardiovascular disease and 2,304 deaths. The researchers found that among men without previous cardiovascular disease, those with severe erectile dysfunction were more likely to develop ischemic heart disease (risk 1.60), heart failure (risk 8.00), peripheral vascular disease (risk 1.92), and other causes of cardiovascular disease (risk 1.26) than men without erectile dysfunction. The risks of heart attacks and heart conduction problems were also increased (1.66 and 6.62, respectively). Furthermore, the combined risk of all cardiovascular disease outcomes was 1.35, and the overall risk of death was also higher (risk 1.93) in these men. The researchers found that these increased risks were similar in men with erectile dysfunction who had previously been diagnosed with cardiovascular disease.

Citation: Banks E, Joshy G, Abhayaratna WP, Kritharides L, Macdonald PS, et al. (2013) Erectile Dysfunction Severity as a Risk Marker for Cardiovascular Disease Hospitalisation and All-Cause Mortality: A Prospective Cohort Study. PLoS Med 10(1): e1001372. doi:10.1371/journal.pmed.1001372

Copyright: © 2013 Banks et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

via PLOS Medicine: Erectile Dysfunction Severity as a Risk Marker for Cardiovascular Disease Hospitalisation and All-Cause Mortality: A Prospective Cohort Study.

Pathophysiology, Diagnosis, and Management of Proteinuria – JAAPA

KEY POINTS

Microalbuminuria tends to occur long before clinical proteinuria becomes evident.

Proteinuria results when the glomerular basement membrane allows excess proteins into the tubular filtrate and when the proximal tubules are unable to reabsorb low-molecular-weight proteins.

False-negative dipstick results may occur if the urine is dilute or if protein loss is mild.

Correlation between the urine protein-creatinine ratio (UPCR) and the 24-hour urine collection has been demonstrated in several diseases, and recent evidence indicates that the UPCR ratio is more accurate than the 24-hour measurement.

The albumin-to-creatinine ratio is more sensitive than the UPCR.

Renal biopsy should be considered in adults with persistent proteinuria because results are likely to guide specific therapy.

via The pathophysiology, diagnosis, and management of proteinuria – JAAPA.

NEJM Resident eBulletin – Elevated PSA

Teaching Topic

Elevated PSA

Case Records of the Massachusetts General Hospital

Case 9-2012: A 67-Year-Old Man with a Persistently Elevated PSA Level

D.S. Kaufman and Others

CME Exam

At least 30% of clinically important prostate cancers may be missed during transrectal ultrasound-guided biopsy, and the results are not improved if more than 12 cores are taken (so-called “saturation biopsies”).

Clinical Pearls

Clinical Pearl  What is a Gleason score?

The Gleason score is the sum of the two most common histologic grades in a prostate-gland tumor, each of which is rated on a scale of 1 to 5, with 5 being the most cytologically aggressive. It correlates with prognosis. A higher score is more likely to be seen with disease that is not confined to the prostate, and is also correlated with poorer response to treatment of localized disease.

Clinical Pearl  What are the criteria for active surveillance in prostate cancer?

The authors report that criteria for active surveillance for prostate cancer include a PSA level less than 10 ng per milliliter. While the decision to carry out active surveillance is one that must be individualized, in general, in addition to having a relatively low PSA, patients with early clinical disease stage and a Gleason score indicating well or moderately differentiated tumor may be considered for active surveillance.

Morning Report Questions

Q. What is transperineal template-guided mapping biopsy (TTMB) of the prostate?

A. Traditional transrectal ultrasound-guided needle biopsy of the prostate allows excellent and convenient sampling of the posterior aspect of the prostate gland, where prostate cancers most commonly originate. On occasion, however, the cancer may arise either centrally or anteriorly and may be beyond the reach of a biopsy needle inserted through the rectum. However, the anterior gland can be reached through a perineal approach, a technique that is used to insert radioactive seeds into the prostate gland for the purpose of treatment (brachytherapy). Precision is needed to ensure that the needles are placed correctly. To achieve this, transrectal ultrasonography is used to visualize the needles, and the needles themselves are passed through holes in a template (grid) that is secured against the perineum. The perforations ensure that the needles are inserted in parallel and with a known relationship to one another. The “repurposing” of this brachytherapy technique for prostate biopsy is known as TTMB, or “grid” biopsy, and the template may be used to insert biopsy needles precisely to any location in the prostate gland.

Figure 3. Transperineal Template-Guided Mapping Biopsy of the Prostate.

Q. What are the indications for consideration of TTMB?

A. A PSA level higher than expected for the size of the gland should prompt consideration of TTMB for better sampling of the prostate. Biopsies performed with the use of templates are important for carefully selected patients in whom there is an unexplained discordance between PSA readings and findings on examination of biopsy specimens obtained via transrectal approach. One quarter of patients who undergo TTMB after at least one negative specimen obtained by transrectal ultrasound-guided biopsy will have positive results on TTMB. Up to half of these patients have cancers with a Gleason score of 7 or higher. In patients with two or more negative specimens from transrectal ultrasound-guided biopsies, the most common finding in specimens obtained by TTMB was cancer in the anterior lobes. The morbidity associated with TTMB is greater than that associated with transrectal ultrasound-guided biopsies; there is a higher incidence of acute urinary obstruction. Overall, the costs associated with TTMB (e.g., the costs of general anesthesia, the operating room, and the processing of a large number of tissue cores) render it far more expensive than transrectal ultrasound-guided biopsies.