Biomedical subjects

J C Presti

Publications and source records attributed to J C Presti.

At least 19 recordsLinked to original sources

PubMed2003

Is there a difference in outcome after radical prostatectomy between patients with biopsy Gleason sums 4, 5, and 6? Results from the SEARCH database.

PURPOSE: Fewer patients newly diagnosed with prostate cancer today have biopsy Gleason sums <6 compared to several years ago. Several tables and nomograms for predicting disease recurrence after definitive therapy provide little or no discrimination between biopsy Gleason sums 4, 5, and 6. We sought to examine the significance of biopsy Gleason sum for predicting biochemical failure following radical prostatectomy (RP) for men with biopsy Gleason sums of 4, 5, and 6. MATERIALS AND METHODS: We examined data from 988 men treated with RP between 1988 and 2002 who had biopsy Gleason sums of 4-6. Clinical and pathological variables as well as outcome information were compared between men with biopsy Gleason sums of 4-6. The log-rank and Cox proportional hazards analysis were used to determine whether biopsy Gleason sum provided unique prognostic information for men with low biopsy Gleason sums undergoing RP. RESULTS: There was statistically significant, but overall weak correlation between biopsy Gleason sum and Gleason sum of the RP specimen (Spearman's r=0.277, P<0.001). As biopsy Gleason sum increased from 4 to 5 to 6, there was a steady rise (HR=1.31 for each one point increase in Gleason sum, Cox's model) in the risk of PSA failure (P=0.025, log-rank). On multivariate analysis comparing biopsy Gleason sum, preoperative PSA, clinical stage, year of surgery, percent of biopsy cores positive, and age for their ability to predict time to biochemical recurrence, only PSA (HR 2.09, CI 1.56-2.80, P<0.001) and biopsy Gleason sum (HR 1.33, CI 1.05-1.70, P=0.019) were significant independent predictors of PSA failure. CONCLUSIONS: Despite weak correlation between biopsy and pathologic Gleason sum among men with biopsy Gleason sum 4-6 tumors, grade was a significant independent predictor of PSA failure following RP. In the range of 4-6, biopsy Gleason sum acted as a continuous variable for predicting PSA failure. The routine use of Gleason sums 4 and 5 to grade prostate needle biopsy specimens should not be abandoned.

Biopsy, Needle↗

PubMed2000

Late presentation of ureteral injury after laparoscopic surgery.

OBJECTIVE: To describe clinical presentation, etiology, and treatment of ureteral injuries recognized late in women who had gynecologic laparoscopies. METHODS: We reviewed the charts of 12 women who had delayed recognition of ureteral injuries between January 1991 and December 1998. RESULTS: Patients presented with fever, hematuria, flank pain, or peritonitis between 3 and 33 days postoperatively. The mechanism of ureteral injuries was electrocoagulation in seven women, laser ablation in one, and stapler ligation in four. The sites of injury were near the inferior margin of the sacroiliac joint on excretory urogram in eight women and near the ureterovesical junction in four. Three women initially treated with internal ureteral stents were subsequently treated with ureteroneocystostomy because of progression of urinary ascites in two and a delayed ureteral stricture in one. In nine patients, attempts at ureteral stenting were unsuccessful and immediate ureteral reconstruction was done. Outcomes were good in all cases. CONCLUSION: Delayed recognition of ureteral injury after gynecologic laparoscopy was associated with serious complications, and initial treatment with ureteral stenting was not useful. We advocate early open repair for those injuries.

Adult↗

PubMed2000

Prostate cancer: assessment of risk using digital rectal examination, tumor grade, prostate-specific antigen, and systematic biopsy.

Refinement in the local staging and risk assessment for prostate cancer patients utilizing clinical parameters is ongoing. DRE, tumor grade, and PSA provide some useful information for risk assessment in individual patients. More recent studies using percent free PSA levels and systematic biopsy results have added additional staging information and may play a more significant role in the future in risk assessment. This information should supplement additional imaging tests in the management of these patients.

Biopsy, Needle↗

PubMed2000

Potential role of nephrectomy in the treatment of metastatic renal cell carcinoma: a retrospective analysis.

OBJECTIVES: To examine the outcomes of patients with newly diagnosed metastatic renal cell carcinoma (RCC) who underwent initial nephrectomy as a component of therapy, because the role of nephrectomy in the treatment of patients with metastatic RCC is uncertain. METHODS: A retrospective review of 63 patients who underwent radical nephrectomy with or without additional surgical procedures in the setting of metastatic RCC was performed. Pretreatment characteristics and the type of surgery were examined as predictors of outcome, and the type of systemic therapy received (if any) and overall survival were determined. RESULTS: The median patient age was 59 years (range 39 to 79). Thirty-two patients had a single metastatic site, with the most common sites being the lung (n = 33), lymphatics (n = 32), and bone (n = 19). Seventeen patients (27%) also underwent vena cavotomy during surgery. Two patients died perioperatively. Thirty-nine (62%) patients underwent systemic therapy after surgery, and 6 patients (9.5%) were rendered free of disease and elected not to receive systemic treatment. The median survival was 17.8 months. CONCLUSIONS: Primary renal surgery may be beneficial for selected patients with metastatic RCC, and most patients will be able to receive postoperative systemic therapy.

Adult↗

PubMed2000

The optimal systematic prostate biopsy scheme should include 8 rather than 6 biopsies: results of a prospective clinical trial.

PURPOSE: We define the optimal systematic biopsy regimen to detect carcinoma of the prostate. MATERIALS AND METHODS: A total of 483 consecutive patients referred for an abnormal digital rectal examination and/or prostate specific antigen (PSA) 4.0 ng./ml. or greater underwent transrectal ultrasound and systematic biopsy. Lateral biopsies of the peripheral zone at the base and mid gland were added to the routine sextant biopsy regimen for a total of 10 systematic biopsies of the peripheral zone. Patients with a prostate greater than 50 cc also underwent systematic sextant transition zone biopsy in the mid lobar parasagittal plane. Detection rates of the various regions were assessed. Various biopsy schemes were then created and cancer detection rates were compared using McNemar's test. RESULTS: Of the patients 42% (202 of 483) had cancer on biopsy. Traditional sextant biopsies missed 20%, while a sextant regimen incorporating lateral peripheral zone biopsies of the mid gland and base along with the apex missed 11% of the cancers. The combination of sextant and lateral peripheral zone biopsies (10-biopsy scheme) detected 194 cancers (96%). The 8 missed cancers were detected by lesion directed (5) or transition zone (3) biopsies. Eliminating the mid lobar base biopsies from the systematic 10-biopsy peripheral zone regimen resulting in an 8-biopsy peripheral zone regimen decreased detection from 96% to 95%. CONCLUSIONS: The 6 systematic biopsies of the peripheral zone are inadequate and a minimum of 8, including the apex, mid lobar mid gland, lateral mid gland and lateral base, should routinely be performed.

Aged↗

PubMed2000

Contemporary approach to the classification of renal epithelial tumors.

Our understanding of the morphologic and genetic features of renal epithelial neoplasia has brought about profound changes in the classification of these tumors. It is clear that they represent a heterogeneous group of tumors with distinct histopathologic, genetic, and clinical features ranging from benign to high-grade malignant. "Granular" and "sarcomatoid" carcinomas are not distinct entities, since tumors with granular or spindle cell features may be seen in many tumor-types. Using conventional pathologic tools such as hematoxylin and eosin staining, histochemistry, immunohistochemistry, and electron microscopy, we are able to properly classify the majority of these tumors. Nevertheless, approximately 6% to 7% of cases are impossible to classify in this fashion, thus requiring molecular genetic studies for proper characterization.

Adenoma, Oxyphilic↗

PubMed2000

Management of a positive surgical margin after radical prostatectomy: decision analysis.

PURPOSE: We created and tested a decision analysis model to help determine the preferred management of a positive surgical margin(s) after radical prostatectomy. MATERIALS AND METHODS: We constructed a decision tree modeling surveillance versus immediate prophylactic adjuvant radiation in patients with a positive surgical margin(s) after radical prostatectomy. Literature and institution based estimates were determined for certain factors, including the probability of undetectable prostate specific antigen (PSA) in patients followed expectantly postoperatively and those treated with immediate adjuvant radiotherapy, complications of radiotherapy after prostatectomy and probability of undetectable PSA in those treated with therapeutic radiation for detectable PSA postoperatively. A panel of experts assigned utilities to the various outcomes. Sensitivity analysis was performed to determine threshold values required to change the model outcome. RESULTS: Using average probability estimates from a literature review the decision model recommended initial surveillance. Sensitivity analysis demonstrated that the model depended on the probability of disease recurrence in men followed expectantly after surgery as well as the efficacy of therapeutic radiation. We tested the decision model again for patient groups based on tumor grade, pathological stage, preoperative PSA and number of positive margins. The model recommended initial radiation for patients with low to intermediate grade disease, no evidence of seminal vesicle invasion and multiple positive margins. CONCLUSIONS: The results of our decision analysis imply that immediate radiation may be appropriate for patients with a positive surgical margin(s) and a high likelihood of recurrent local rather than distant disease. This model may be useful to physicians and patients who use individual probability estimates and utility values to determine the preferred course of management after surgery.

Decision Trees↗

PubMed1999

Number of positive systematic sextant biopsies predicts surgical margin status at radical prostatectomy.

OBJECTIVES: To determine whether the number of positive sextant biopsies contributes to the prediction of positive surgical margins, as the value of systematic prostate biopsies in predicting margin status at radical prostatectomy is unclear. METHODS: Consecutive patients (n = 108) who underwent radical retropubic prostatectomy and systematic sextant biopsies were retrospectively evaluated. Serum prostate-specific antigen, digital rectal examination, primary Gleason grade, Gleason score, and the number and location of positive sextant biopsies were recorded for each patient. Radical prostatectomy specimens were evaluated by step-section techniques at 3 to 5-mm intervals. Univariate comparisons for each of these variables was performed between the positive and negative margin groups using the Mann-Whitney U test or chi-square analysis. Logistic regression analysis was performed for these variables. RESULTS: Twenty-two (20.4%) of 108 patients had a positive surgical margin because of extension of the tumor through the capsule. Patients with three or more positive biopsies were at higher risk of having a positive surgical margin (P = 0.009). Patients with bilaterally positive biopsies at either the base or midprostate were more likely to have a positive surgical margin. The risk of a positive surgical margin was not significantly determined by the primary Gleason grade, Gleason score, or prostate-specific antigen. Multivariate logistic regression models were created that consistently demonstrate that the number of positive biopsies was the best predictor of margin status. CONCLUSIONS: This study demonstrated that the number of positive sextant biopsies contributes to the prediction of margin status at radical prostatectomy.

Aged↗

PubMed1999

The role of the urologist in adjuvant chemotherapy trials for prostate cancer.

The urologist is ideally positioned to identify patients at high risk for relapse after radical prostatectomy. Several models have been proposed to help the urologist identify which patients are at risk and who should be considered for adjuvant therapy after radical prostatectomy. The appropriate initial trial design considered for this group of patients should be a randomized two-arm trial, without androgen deprivation, to assess more quickly the efficacy of selected agents.

Antineoplastic Agents↗

PubMed1999

Diffuse retroperitoneal amyloidosis due to renal cell carcinoma.

The case of a 61-year-old man with haematuria, in whom CT demonstrated a solid renal mass and extensive retroperitoneal infiltration, is presented. This combination of CT findings resulted in significant diagnostic uncertainty. Pathological analysis demonstrated renal cell carcinoma, with secondary amyloidosis in the retroperitoneum. Amyloidosis secondary to renal cell carcinoma has not been previously described as a cause of retroperitoneal infiltration.

Amyloidosis↗

PubMed1999

The efficacy of cryosurgical ablation of prostate cancer: the University of California, San Francisco experience.

PURPOSE: We analyze biopsy and prostate specific antigen (PSA) results following cryosurgery for patients with clinically localized prostate cancer. MATERIALS AND METHODS: A total of 176 patients underwent 207 cryosurgical procedures for clinically localized (stages T1 to T4) prostate cancer using a multiprobe cryosurgical device. Cancer stage was T1 in 8.7%, T2 in 30%, T3 in 59% and T4 in 2.3% of the 176 patients. Neoadjuvant androgen deprivation was delivered to 101 patients (57%). End points used to determine efficacy of the procedure included analysis of posttreatment serum PSA characteristics (nadir and nonrising status) and biopsy results (absence of cancer). Cryosurgery was considered successful if PSA reached a nadir of less than 0.5 ng./ml. and did not increase by more than 0.2 ng./ml. on 2 consecutive occasions. Mean followup for the entire group was 30.8 months, with 122 patients (60%) followed for 24 or more months and 75 (36%) followed for 36 or more months. RESULTS: Serial PSA data was available after 181 initial and repeat procedures. Nadir PSA was undetectable in 88 patients (49%), between 0.1 and 0.4 ng./ml. in 39 (21%) and 0.5 ng./ml. or greater in 54 (30%) following cryosurgery. After 78 of these procedures (43%) serum PSA reached a nadir of less than 0.5 ng./ml. and failed to increase greater than 0.2 ng./ml. on at least 2 occasions. Prostate biopsy was performed following 167 procedures and was positive after 64 (38%). CONCLUSIONS: Cryosurgery was associated with favorable serum PSA characteristics in 49% of patients 3 years after treatment. Undetectable PSA nadir and pretreatment PSA 10 ng./ml. or less were associated with a favorable outcome, with a biochemical disease-free survival of 77% and 61% 3 years after treatment, respectively.

Actuarial Analysis↗

PubMed1998

EGF-r gene copy number changes in renal cell carcinoma detected by fluorescence in situ hybridization.

Expression of epidermal growth factor receptor (EGF-r) is a frequent event in renal cell carcinoma (RCC). To investigate the role of EGF-r gene copy number changes related to EGF-r overexpression, 50 RCC specimens were examined by fluorescence in situ hybridization (FISH) and immunohistochemistry. Dual-labelling FISH with a repetitive pericentromeric probe for chromosome 7 and a probe for the EGF-r gene (at 7p13) was performed to analyse the EGF-r copy number in relation to chromosome 7 copy number on a cell-by-cell basis. Polysomy 7 was frequent in all histological types of RCC. Chromosome 7 polysomy was found in 26 of 35 clear cell (74 per cent), nine of nine papillary, and three of three chromophobe RCCs. EGF-r gene copy number was closely associated with the chromosome 7 copy number on a cell-by-cell basis. No EGF-r gene amplifications were found. EGF-r positivity was found in 37 of 50 cases (74 per cent) by immunohistochemistry. EGF-r positivity was more common in clear cell (81 per cent) than in papillary tumours (40 per cent; P = 0.029). Neither chromosome 7 nor EGF-r gene copy number was associated with EGF-r expression, indicating that an increased gene dosage is not a mechanism of EGF-r overexpression in RCC.

Carcinoma, Renal Cell↗

PubMed1998

Prospective evaluation of systematic sextant transition zone biopsies in large prostates for cancer detection.

OBJECTIVES: A prospective evaluation was performed to define the role of systematic transition zone (TZ) biopsies in prostates larger than 50 cc. METHODS: From August 1994 to July 1997, 213 consecutive patients referred because of an abnormal digital rectal examination or prostate-specific antigen greater than 4.0 ng/mL had a calculated prostate size greater than 50 cc by transrectal ultrasound (TRUS) measurement. These patients underwent TRUS-guided sextant biopsies of the peripheral zone (PZ) and TZ. RESULTS: The median calculated prostate size was 70 cc with a TZ size of 39 cc. Fifty-five cases of carcinoma of the prostate were found, giving a 26% detection rate. The TZ biopsies detected cancer in 30 of the 55 patients (55% sensitivity) compared with the 47 patients detected by the PZ biopsies (85% sensitivity). Seven cancers (13%) were detected only by the additional TZ biopsies. TZ biopsies revealed bilateral tumors when the PZ biopsies had shown unilateral disease in 2 cases. In 6 cases the TZ biopsies showed higher Gleason grade tumors than was found in the PZ. In the 30 cases with positive TZ biopsy, concordance between the PZ and TZ biopsies occurred in 74% (133 of 180) of the sectors. The PZ biopsy detected cancer in 43 of 66 corresponding sectors that had positive TZ biopsies, giving a sensitivity of 65% and a negative predictive value of 80%. CONCLUSIONS: Routine PZ biopsies missed detecting 13% of the cancers found with the addition of sextant TZ biopsies in patients with large prostates (greater than 50 cc). In addition, 14% of the patients with cancer had upgrading or detection of bilateral tumor with the added biopsies. Routine systematic sextant TZ biopsies should be considered in patients with prostates greater than 50 cc in size.

Aged↗

PubMed1998

Positive fraction of systematic biopsies predicts risk of relapse after radical prostatectomy.

OBJECTIVES: To determine whether the positive fraction of systematic sextant biopsies contributes to the prediction of serologic relapse after radical prostatectomy. METHODS: A retrospective review of patients who underwent transrectal ultrasound-guided systematic sextant biopsy and radical prostatectomy was performed. No patients received neoadjuvant or adjuvant therapy. The relationship between the positive fraction of systematic biopsies and risk of prostate-specific antigen recurrence was assessed with Kaplan-Meier and multivariate analyses. RESULTS: Patients with three or fewer positive sextant biopsies were at a significantly lower risk of relapse after radical prostatectomy than patients with four or more positive biopsies. Tumor grade and systematic biopsy results were the most powerful predictors of serologic relapse. CONCLUSIONS: The positive fraction of systematic biopsies contributes to the prediction of risk of relapse after radical prostatectomy.

Aged↗

PubMed1998

Imaging and management of atypical testicular masses.

Most testicular masses are germ cell malignancies and require radical orchiectomy. There are other causes of testicular masses, however, some of which have characteristic imaging and clinical features. A presumptive diagnosis may be possible for some of these atypical testicular masses. This may result in testis-preserving surgery or nonoperative management.

Diagnosis, Differential↗

PubMed1998

Prospective evaluation of lateral biopsies of the peripheral zone for prostate cancer detection.

PURPOSE: We evaluate the usefulness of adding 4 lateral biopsies of the peripheral zone to the routine sextant biopsy regimen for prostate cancer. MATERIALS AND METHODS: A total of 273 consecutive patients referred for abnormal digital rectal examination and/or prostate specific antigen 4 ng./ml. or greater underwent transrectal ultrasound and systematic biopsy. Lateral biopsies of the peripheral zone taken just medial to the lateral border of the prostate were added to the routine lesion directed and systematic sextant biopsy regimen. Comparisons between positive and negative biopsy groups as well as among various biopsy schemes were performed. RESULTS: Of the patients 44% had cancer on biopsy (121 of 273). While routine sextant biopsies detected 82% of cancers, 77% (17 of 22) of missed cancers were detected on lateral biopsies. Overall, lateral biopsies detected 70% of cancers, and tended to be positive in patients with small prostates and high grade tumors. A significant correlation was found between hypoechoic lesions on transrectal ultrasound and positive lateral biopsies (Fisher's exact test p = 0.0005). Cancer was found in 74 of 147 patients with lesions on transrectal ultrasound (50%). Routine sextant biopsies detected 76% of cancers (56 of 74 patients) while lateral biopsies detected 80% (59). Of these patients 15 (20%) had positive lateral and negative sextant biopsies. Routine sextant biopsies detected 91% of cancers in 121 patients without lesions on ultrasound (43 of 47). CONCLUSIONS: The addition of lateral peripheral zone biopsies increases the sensitivity for cancer detection while nearly eliminating the need for lesion directed biopsies.

Aged↗

PubMed1998

Initiating genetic events in small renal neoplasms detected by comparative genomic hybridization.

PURPOSE: To identify the genetic alterations associated with renal adenomas. MATERIALS AND METHODS: We analyzed 37 renal adenomas obtained at autopsy (23 papillary and 14 non-papillary) by comparative genomic hybridization. RESULTS: In papillary tumors, the median number of gains and losses of genetic material per tumor was 2.0 and 1.0, respectively. Papillary tumors were characterized predominantly by gains of genetic material on chromosomes 7 (57%), 17 (35%), 16 (26%), 12 (26%), 3 (22%), 20 (22%) and loss of a sex chromosome (83%). In 6 papillary tumors less than or equal to 5 mm. in diameter, gain of chromosome 7 occurred in 4 specimens. Initiating events for papillary renal adenomas include gain of chromosome 7 and loss of a sex chromosome. In non-papillary tumors, the median number of gains and losses of genetic material per tumor was 1.0 and 1.0, respectively. Non-papillary tumors were characterized by loss of genetic material on chromosome 3p (50%), loss of a sex chromosome (36%) and a gain of chromosome 5 (43%). The initiating event for non-papillary renal adenomas is the loss of chromosome 3p. CONCLUSIONS: Renal adenomas demonstrate similar genetic alterations as clinically detected renal cell carcinomas. Their clinically indolent course may, in part, be a result of the lower number of genetic alterations per tumor than their clinically detected counterparts. Renal adenomas are thus small carcinomas which have not yet acquired the necessary genetic alterations leading to tumor progression.

Aged↗

PubMed1998

Radiation therapy for the management of biopsy proved local recurrence after radical prostatectomy.

PURPOSE: We determine which clinical characteristics correlate with a successful outcome following external beam radiation for the management of biopsy proved, locally recurrent prostate cancer after radical prostatectomy. MATERIALS AND METHODS: The clinical records of 34 patients who were treated at our institution with external beam radiation for biopsy proved local disease recurrence after radical prostatectomy were reviewed. Mean followup was 77.9 months after radical prostatectomy and 38.3 months after radiotherapy. Preoperative, postoperative and pathological characteristics were examined for the ability to predict failure following radiotherapy. RESULTS: Of the 34 patients 9 (26%) exhibited persistently low and stable serum prostate specific antigen (PSA) (less than 0.5 ng./ml.), while 7 (21%) had an undetectable serum PSA (less than 0.1 ng./ml.) during followup. These 16 patients were considered to be successfully treated by radiation and in the remaining 18 (53%) radiation was considered to have failed. The likelihood of successful treatment at 3 years after radiotherapy for all patients was 48%. Preoperative PSA, PSA at first elevation, postoperative PSA velocity and pathological stage were not significant predictors of a successful outcome following radiation treatment. Patients with a serum PSA of 4 ng./ml. or less before receiving radiotherapy and those with a prostatectomy specimen Gleason score of 7 or less were significantly more likely to be successfully treated by radiotherapy. CONCLUSIONS: Radiation therapy is a viable treatment option for select patients with biopsy proved local disease recurrence following radical prostatectomy. The chance of achieving and maintaining a persistently low and stable or undetectable serum PSA is likely in those patients with a prostatectomy specimen Gleason score of 7 or less and a pre-radiation PSA of 4.0 ng./ml. or less. More effective treatment regimens are needed for those patients in whom radical prostatectomy fails.

Aged↗