Search

INTRODUCTION AND OBJECTIVE:Complication rates following cystectomy range from 40-80% with 75% of complications being related to the urinary diversion. Reported complication following continent cuta... more...

INTRODUCTION AND OBJECTIVE:MRI-guided transurethral ultrasound ablation (TULSA) is a novel minimally-invasive procedure for prostate ablation. We report two-year outcomes from the pivotal TULSA-PRO... more...

INTRODUCTION AND OBJECTIVES:We sought to assess if pembrolizumab (pembro) improves the pathologic response rate in locally advanced urothelial carcinoma (UC) when combined with gemcitabine (G) and ... more...

INTRODUCTION AND OBJECTIVES:MRI-guided transurethral ultrasound ablation (TULSA) is a novel minimally-invasive procedure for customized prostate ablation. We report one-year outcomes from the TULSA... more...

INTRODUCTION AND OBJECTIVES:The utilization of PSA for the diagnosis of prostate cancer has been recently challenged due to poor sensitivity. Because PSA remains a surrogate for BPH and prostate si... more...

Poorly differentiated sinonasal carcinomas are a heterogenous group of aggressive neoplasms that encompasses squamous cell carcinoma including basaloid variant, lymphoepithelial carcinoma, sinonasal undifferentiated carcinoma, and neuroendocrine-type small cell carcinoma. We herein describe 3 cases of a hitherto unreported variant combining features of basaloid carcinoma with variable intermingled rhabdoid cells. Patients were 2 women (aged 28 and 35) and a man (52 y) who presented with sinonasal masses. All had advanced local disease with bone involvement (pT4). None had a history of irradiation or a family history of rhabdoid tumors. Treatment was surgery and adjuvant chemoradiation. One patient developed liver, lung, pleural, and pericardial metastases (63 mo) and is currently (70 mo) alive under palliative treatment. Another developed recurrent cervical lymph node metastases and died of disease 8.5 years later. The youngest patient was disease-free at last follow-up 7 years later. Histologic features were very similar in all 3 cases and showed intimate admixture of compact basaloid cell nests with peripheral palisading, perivascular pseudorosettes, and a few scattered rhabdoid cells. Rhabdoid cells were more extensive in the metastasis in 1 case but formed a minor inconspicuous component in the primary tumors in all cases. Striking features common to all cases were (1) basaloid “blue” appearance at low power, (2) papilloma-like exophytic component, (3) extensive pagetoid surface growth with prominent denuding features, and (4) replacement of underlying mucous glands mimicking an inverted papilloma. Clear-cut origin from benign papilloma and overt squamous differentiation were lacking. Diffuse (2) or partial (1) p16 expression was noted, but all cases lacked human papillomavirus DNA by molecular tests. In situ hybridization was negative for Epstein-Barr virus. Immunohistochemistry showed diffuse expression of pancytokeratin. CK5 and vimentin showed intermingling of CK5+/vimentin− basaloid and CK5−/vimentin+ rhabdoid cells. Complete loss of nuclear SMARCB1 expression was seen in all cases including also the denuding carcinoma in situ–like surface lesions. To our knowledge, this variant of sinonasal carcinoma has not been reported before. The identical features in all 3 cases suggest a specific disease rather than a nonspecific dedifferentiated phenotype. Awareness of this rare variant and thus reporting of additional cases is necessary for defining its full morphologic and biological spectrum. more...

We evaluate the incidence and risk factors of parastomal hernia formation in patients undergoing radical cystectomy and ileal conduit urinary diversion.We retrospectively reviewed the Indiana University cystectomy database between 2001 and 2011, and identified 516 patients who underwent radical cystectomy and ileal conduit diversion. Overall 199 patients had a clinical followup of at least 12 months and all underwent postoperative staging computerized tomography to confirm the presence of parastomal hernia. The incidence of parastomal hernia is reported with correlations made to demographic, patient level and perioperative risk factors.A parastomal hernia developed in 58 patients (29%) at a median followup of 27 months (range 12 to 125). Of these patients 26 (45%) underwent surgical repair due to abdominal discomfort (58%), acute strangulation or obstruction of the small bowel (15%), partial small bowel obstructions (15%) and elective repair for other intra-abdominal procedures (12%). Prior exploratory laparotomy (adjusted HR 1.98, 95% CI 1.97-3.36, p = 0.011) and severe obesity (adjusted HR 4.26, 95% CI 1.52-11.93, p = 0.006) were predictive of parastomal herniation. The cumulative risk of parastomal hernia formation at 1 and 2 years after cystectomy was 12.2% and 22.5%, respectively.We demonstrated that parastomal hernia will develop in nearly a third of patients after radical cystectomy with ileal conduit diversion. Prior laparotomy and severe obesity are independent risk factors. Preoperative counseling and preventative measures regarding parastomal hernia formation should be emphasized, particularly in these at risk patients. more...

INTRODUCTION AND OBJECTIVES: Bladder cancer (BCa), may present with variant morphologic features that deviate from the urothelial common aspect. These characteristics that can be defined as pure or mixed variants may have prognostic and therapeutic implications. METHODS: We retrospectively evaluated histopathological data from 1,067 BCa patients treated with radical cystectomy (RC) and PLND for BCa between 1990 and 2013 at a single tertiary care referral center. All specimen were evaluated by dedicated uropathologists. Uniand multivariate Cox regression analyses tested the impact of different histopathological variant CSM (cancer specific mortality) and OM (overall mortality) after accounting for age at surgery, pathological N stage, use of perioperative chemotherapy, number of positive nodes, number of removed nodes, positive surgical margin, pathological T stage, lymph vascular invasion, use of adjuvant chemotherapy. RESULTS: Of 1,067 patients, 756 (70.9%) harbored pure urothelial BCa while 311 (29.1%) were found to have a variant. Of these, 202 (64.9%) had a mixed variant and 109 (35.1%) a pure variant. Considering uncommon variants, 21 (6.8%) were sarcomatoid, 10 (3.2%) lymphoepitelial, 19 (6.1%) small cell, 4 (1.3%) plasmacitoid, 2 (0.6%) nested, 109 (35.0%) squamous, 89 (28.6%) micropapillary, 23 (7.4%) glandular and 34 (10.9%) multiple mixed. With a median follow up of 65 months, CSM and OM were recorded in 365 (34.2%), 451 (42.3%) patients, respectively. The OM was 47% vs. 53% vs. 59% for pure urothelial vs. mixed vs. pure variants, respectively (Log rank p1⁄40.011). The 5-years CSM was 44% vs. 47% vs. 53% for pure urothelial vs. mixed vs. pure variants, respectively (Log rank p1⁄40.019). At MVA Cox regression analyses, the presence of pure histological variant was associated with higher CSM (HR: 1.60, p 0.3). In details, neuroendocrine (HR 4.30, CI 2.02-9.13, p more...

We examined a retrospective cohort of patients with biochemical recurrence after prostatectomy to determine whether prostate specific antigen doubling time would remain stable with time. We also examined the relationship between other clinical parameters and the change in prostate specific antigen doubling time.We retrospectively reviewed the prostate cancer database from 1989 to 2008 to identify patients treated with radical prostatectomy for prostate cancer who experienced prostate specific antigen recurrence. Of the 2,237 patients identified 329 had biochemical recurrence. Prostate specific antigen doubling time was calculated at each visit and linear regression of prostate specific antigen doubling time with time was fit. Rate of change in prostate specific antigen doubling time was defined as the slope of the least squares regression line.Median followup was 5 years (range 0.2 to 18). High Gleason score and local recurrence within 5 years were significantly associated with shorter 2-year prostate specific antigen doubling time and a decreased rate of change in doubling time (p = 0.0096, 0.0119, 0.0195 and 0.0258, respectively). Metastasis within 5 years was significantly associated with shorter 2 and 5-year doubling time (p = 0.0006 and 0.0014, respectively). Using all prostate specific antigen values within 5 years of initial biochemical recurrence yielded an overall median prostate specific antigen doubling time of 52.8 months (range 5.4 to 100.0). The median rate of change in doubling time was -1.05 (range -64.7 to 27.0). Median time to metastasis after biochemical recurrence was 12.9 years.Median prostate specific antigen doubling time decreases with time. This may influence the decision to offer secondary therapy to patients with biochemical recurrence sooner since initial prostate specific antigen doubling time is long and may not accurately reflect the biological nature of the disease. more...

We characterized prostate cancer focality in regard to clinicopathological features, prognostic value and impact on biochemical outcome.We retrospectively reviewed the records of 1,366 patients in our prospective database who underwent radical prostatectomy between 1999 and 2010 for clinically localized prostate cancer with pathological evaluation using whole mount sectioning techniques and tumor mapping. Unifocal disease was defined as the identification of a solitary cancer focus in the prostate without additional tumor foci or satellite lesions, ie multifocal disease, on histopathological evaluation. Cox regression modeling was used to identify predictors of biochemical progression among groups.A total of 184 patients (13%) fulfilled our unifocal tumor criteria. Unifocal tumors tended to be smaller in volume and in greatest diameter than multifocal tumors (p0.0001 and0.005, respectively). Of patients with pathologically insignificant disease the relative proportion with unifocal tumors increased to 28% from 13% in the overall cohort (p0.0005). Also, tumor focality failed to predict biochemical recurrence in univariate and multivariate models. Accordingly we noted no significant differences in 5-year biochemical recurrence-free survival for unifocal and multifocal tumors (66% and 61%, respectively, p=0.76). Limitations of this study include its retrospective nature.In this study tumor focality failed to predict patients likely to experience biochemical failure. Tumor characteristics were similar regardless of focality. However, unifocal tumors had smaller volume and were more commonly seen as clinically insignificant compared to multifocal tumors. more...

We reviewed indications and outcomes in patients undergoing ileal ureter replacement for ureteral reconstruction.Between December 1989 and September 2007, 105 patients underwent ileal ureter replacement, of whom 14 were excluded from study due to incomplete data. The remaining 91 patients (99 renal units) comprised the study cohort.Mean patient age was 46.8 years and mean followup was 36.0 months. Indications for an ileal ureter were stricture following genitourinary surgery in 29 cases (31.9%), radiation induced stricture in 17 (18.7%), nonurological surgery iatrogenic injury in 16 (17.6%) and retroperitoneal fibrosis in 11 (12.1%). Only 4 patients (4.4%) had primary ureteral cancer. Long-term complications included anastomotic stricture in 3 patients (3.3%) and fistula in 6 (6.6%). Serum creatinine decreased or remained stable in 68 patients (74.7%) and hyperchloremic metabolic acidosis developed in 3. No patient complained of excessive urinary mucous production.In 68.1% of patients indications for an ileal ureter included radiation induced stricture or iatrogenic injury. The ileal ureter is a reasonable option for long-term ureteral reconstruction with preserved renal function in carefully selected patients. more...

We examined the safety and potential efficacy of transrectally delivered high intensity focused ultrasound for the full gland ablation of previously untreated localized prostate cancer.A total of 20 patients with localized prostate cancer underwent 1 to 3 high intensity focused ultrasound treatments of the prostate. The primary outcome was safety and the secondary outcomes were prostate specific antigen, prostate biopsy and quality of life measures.A total of 19 patients had complete followup. Serious adverse events related to treatment were limited with the most common adverse event being transient urinary retention more than 30 days in duration in only 10% of patients. Rectal injury occurred in 1 patient. With 1 to 3 treatments 42% of the patients achieved prostate specific antigen less than 0.5 ng/ml and a negative prostate biopsy.High intensity focused ultrasound in patients with previously untreated prostate cancer is generally well tolerated and it has the potential to completely ablate the prostate gland. With further refinement of the optimal treatment dose and technique this technology has the potential to be an effective form of therapy for localized prostate cancer. more...

Tumor volume has been considered an important variable in determining the probability of prostate-specific antigen (PSA) recurrence in prostatic adenocarcinoma. There have been many studies that have tried to determine an appropriate method of calculating tumor volume, but no single methodology has been agreed upon. We tested the hypothesis that the ratio of tumor positive tissue blocks to the total number of blocks submitted (positive-block ratio) can be used as an independent prognostic indicator for PSA recurrence. We analyzed 504 patients who underwent total radical retropubic prostatectomy between 1990 and 1998. None of the patients had preoperative radiation or androgen-deprivation therapy. Clinical records were reviewed. The mean positive-block ratio was 0.44 (median, 0.43; range, 0.05 to 1.0). The positive block-ratio was significantly associated with Gleason score, pathologic stage, surgical margin status, extraprostatic extension, seminal vesical invasion, lymph node metastasis, perineural invasion, and preoperative serum PSA level (all P0.001). Using a multivariate Cox regression model, controlling for pathologic stage, Gleason score, lymph node metastasis, and surgical margin status, positive-block ratio was an independent predictor of PSA recurrence (hazard ratio, 2.3; 95% confidence interval, 1.06-4.83; P=0.03). Five-year PSA recurrence-free survival was 67% for those patients with positive-block ratioor=0.43, as compared with 42% those with positive-block ratio0.43 (P0.001). Positive-block ratio is an independent predictor of PSA recurrence and this simple method of tumor measurement seems to be promising for quantifying tumor volume if our findings are validated by subsequent reports. more...

We investigated whether an online educational program based on spacing effect principles could significantly improve the acquisition and retention of medical knowledge.In this randomized, controlled trial involving urology residents in the United States and Canada participants randomized to cohort 1 (bolus education) were e-mailed a validated set of 96 study questions on 4 urology topic areas in June 2005. Residents in cohort 2 (spaced education) were sent daily educational e-mails during 27 weeks (June to December 2005), each of which contained 1 or 2 study questions presented in a repeating, spaced pattern. In November 2005 participants completed the Urology In-Service Examination. Participants were also randomized to 1 of 5 outcome cohorts, which completed a 32-item online test at staggered time points (1 to 14 weeks) after completion of the spaced education program.Of 537 participants 400 (74%) completed the online staggered tests and 515 (96%) completed the In-Service Examination. Residents in the spaced education cohort demonstrated significantly greater online test scores than those in the bolus cohort (ANOVA p0.001). One-way ANOVA with trend analysis revealed that online test scores for the spaced education cohort remained stable with no significant differences with time, while test scores in the bolus cohort demonstrated a significant linear decrease (p = 0.007). The specific learning gains attributable to Spaced Education were robust when controlling for use of the study materials but they did not generalize to higher scores on the In-Service Examination.Online spaced education improves the acquisition and retention of clinical knowledge. more...

Gleason grade and tumor stage are well established prognostic factors in prostate cancer. Histological demonstration of tumor in lymphovascular spaces has been associated with poor prognosis in many tumor types but it is not included in current prostate cancer grading and staging schemes. Whether lymphovascular invasion is an independent prognostic factor for disease progression in prostate cancer is uncertain. We retrospectively investigated lymphovascular invasion as a predictive factor for biochemical failure and cancer specific survival following radical prostatectomy.The records of 504 patients with prostatic adenocarcinoma undergoing radical prostatectomy were reviewed for lymphovascular invasion. Clinical followup data were available on 459 cases. Mean followup was 44 months (range 1.5 to 144). Multivariate analysis was performed using the Cox model.Lymphovascular invasion was identified in 106 cases (21%). Univariate analysis showed a significant association between lymphovascular invasion and higher preoperative serum prostate specific antigen (PSA), advanced pathological stage, higher Gleason score, positive surgical margins, extraprostatic extension, seminal vesicle invasion, lymph node metastasis and perineural invasion (each p0.001). No association was observed between lymphovascular invasion and patient age at surgery, prostate weight or high grade prostatic intraepithelial neoplasia. Lymphovascular invasion was an independent predictor of PSA recurrence (HR 1.6, 95% CI 1.12 to 2.38, p = 0.01) and cancer specific survival (HR 2.75, 95% CI 1.04 to 2.28, p = 0.041) after controlling for tumor stage, surgical margins and Gleason grade on multivariate analysis. Five-year cancer specific survival was 90% in men with lymphovascular invasion compared to 98% in those without lymphovascular invasion (p0.001).Lymphovascular invasion can be identified in approximately 20% of prostate cancer cases. Lymphovascular invasion is an independent risk factor for PSA recurrence and cancer death in patients with prostate cancer. more...

The detection of low volume and early stage prostate cancer has increased with the widespread use of prostate specific antigen screening for prostatic adenocarcinoma. This increased detection has led to efforts to stratify patient risk and the potential benefits of various treatments based on preoperative clinical and biopsy data. We examined various clinical parameters and prostate biopsy features to determine which variables are most predictive of small volume (less than 0.5 ml) cancer at prostatectomy.We studied 336 patients who underwent prostatectomy for prostate cancer. Radical prostatectomy specimens were completely embedded and whole mounted. Final tumor volume in the radical prostatectomy specimens was determined by the grid method. Clinical data were gathered by a review of patient charts. Various preoperative clinical and biopsy findings were analyzed to determine factors predictive of small volume cancer at prostatectomy.A total of 55 patients (16%) were found to have small volume cancer (less than 0.5 ml). On univariate logistic regression certain variables were significant predictors of small volume cancer, namely the highest Gleason score from all positive biopsy sites (p = 0.001), the Gleason score from the biopsy site with the highest percent of adenocarcinoma (p = 0.006), the highest percent of adenocarcinoma at any biopsy site (p0.0001), the percent of adenocarcinoma at the biopsy site with the highest Gleason score (p0.0001), the highest percent of cores positive for adenocarcinoma at any biopsy site (p = 0.001), the percent of cores with carcinoma at the site with the highest Gleason score (p = 0.002), the number of positive sites (p0.0001) and tumor bilaterality (p0.0001). None of the clinical parameters that we studied, including preoperative prostate specific antigen (p = 0.52), clinical stage (p = 0.62) or patient age (p = 0.94), was predictive of small volume cancer. On multivariate analysis the highest percent of adenocarcinoma at any site (adjusted OR 0.95, 95% CI 0.92 to 0.97, p0.0001) and the number of positive biopsy sites (adjusted OR 0.97, 95% CI 0.96 to 0.99, p0.0001) were significant predictors of small volume cancer.The number of positive biopsy sites and the highest percent of adenocarcinoma at any biopsy site are significant predictors of small volume cancer in radical prostatectomy specimens. more...

Complete removal of the tumor by surgery offers the best chance for cancer cure; however, many prostate cancer patients who have negative surgical margins at radical prostatectomy will still experience local and distant tumor recurrence. In other organs, the closest distance between tumor and resection margin has prognostic significance. This has not been adequately studied in prostatectomy specimens. We undertook a prospective study of 278 consecutive margin-negative whole-mount prostatectomy cases. The anatomic location and closest distance between tumor and resection margin, measured with an ocular micrometer, were analyzed. All the slides were reviewed by a single pathologist, and data were collected prospectively. The closest distance between tumor and resection margin ranged from 0.02 to 5.0 mm (mean, 0.7 mm; median, 0.5 mm) and correlated with patient age (P = 0.03), prostate weight (P = 0.002), Gleason score (P = 0.001), pathologic stage (P = 0.01), tumor volume (P < 0.001), and perineural invasion (P < 0.001). The closest distance between tumor and resection margin was not a significant predictor of PSA recurrence in univariate or multivariate logistic regression; and we do not, therefore, advocate reporting the closest distance between tumor and resection margin as a standard part of the surgical pathology report on prostatectomy specimens. more...

Prediction of outcome in patients with meningiomas remains a significant problem to date. We have evaluated the role of symptoms at presentation and overexpression of her-2/neu overexpression as independent prognostic factors in meningiomas. In a retrospective study on patients with biopsy-proven diagnosis of meningioma, her-2/neu overexpression was evaluated using immunohistochemistry (IHC) performed on paraffin-embedded specimens. An IHC score ofor =2+ was considered positive for overexpression. Two hundred thirty-seven patients thus identified between January 1986 and December 1999 included 149 females and 88 males, with a mean age of 63.44 years. Survival was estimated using the Kaplan-Meier method. Incidence of meningiomas in females (62.8%) was significantly greater than in males. Focal neurodeficits, headache, and seizures (39.66%) were the most common presenting complaints and were not related to tumor behavior/outcome. Syncope at presentation was associated with a decreased survival, but this symptom constituted only 2.53% of the total, so reliable conclusions could not be drawn. Only 6 (2.53%) specimens revealed HER-2/neu overexpression by IHC. HER-2/neu overexpression is not a predictor of tumor behavior and has no role as a prognostic factor in meningiomas. Syncope as the clinical presentation at diagnosis may predict a poor outcome, but needs further investigation. more...

Purpose: We assessed the incidence of and analyzed factors that may help prevent major complications and open conversion during laparoscopic nephrectomy at our institutions.Materials and Methods: We retrospectively analyzed all laparoscopic nephrectomies performed between August 1, 1999 and July 31, 2001. Data were stratified for nephrectomy type, intraoperative and postoperative complications. Conversion to open surgery was stratified for emergency versus elective procedures.Results: Of the 292 laparoscopic procedures performed at our institutions in 2 years 213 (73%) involved laparoscopic nephrectomy, including 84 live donor nephrectomies, 61 radical nephrectomies, 55 simple nephrectomies and 13 nephroureterectomies. A total of 16 major complications (7.5%) occurred, including access related, intraoperative and postoperative complications in 3, 9 and 4 cases, respectively. The conversion rate was 6.1% (13 patients), the transfusion rate was 1.9% and the mortality rate was 0.5% (1 death). Only 1 ... more...

INTRODUCTION AND OBJECTIVES: NCCN guideline recommends adjuvant chemotherapy for upper tract urothelial carcinoma (UT-UC) based upon pT stage and the presence of lymph node (LN) involvement. However, lymph dissection (LD) for UT-UC is not universally performed. Lymphovascular invasion (LVI) is characterized by the presence of tumor cells inside small lymphatic channels and veins and its association with LN involvement has been described in other genitorurinary tumors. Herein we sought to evaluate if LVI can be used as a prognostic surrogate for LN involvement in patients without LD during surgery. METHODS: Patients undergoing surgical treatment for UT-UC at Indiana University from 1994-2012 were evaluated. Clinicopathologic outcomes, and follow up was obtained through medical records and the IU cancer registry data. Survival analysis was performed using the logrank test and multivariable Cox proportional hazards. Primary outcome was disease-specific survival (DSS). RESULTS: We identified 131 patients with median follow up of 61.5 months. pT stage was T2 or less in 88 (67.7%) patients and 100 (76.3%) had high grade disease. LD was performed in 62 (47.3%) patients: 43 (32.8%) were node negative (N0) and 19 (14.5%) node positive (N+); 69 (52.7%) did not have LD (Nx). LVI was present in 29 patients of whom 5 were N0, 12 N+ and 12 Nx. The specificity of LVI for N+ disease in the LD group was 88.4% (95% CI 74.1-95.6). Compared to N0,Nx LVI negative patients had similar DSS (p1⁄40.882), while N+ and NxLVI+ patients had significantly worse DSS (p more...

Purpose: We determined how prostate specific antigen (PSA) doubling time changed with time and whether an early measure of doubling time would accurately predict long-term PSA values and clinical outcome in a cohort of patients followed expectantly after radical prostatectomy.Materials and Methods: We analyzed data on 121 patients with PSA recurrence after radical retropubic prostatectomy. Group and individual analyses were performed on 60 patients who met study inclusion criteria. PSA doubling time was calculated and a curve was plotted using logarithmic transformation with linear regression and least squares analysis. In analysis 1 patients were placed into 3 subgroups according to doubling time. Doubling time was calculated per subgroup and the slopes of the aggregate curves were compared to determine how doubling time changed with time. In analysis 2 we calculated early doubling time per patient using only the initial 2 detectable PSA values and compared it with eventual doubling time in each using al... more...

Purpose: We reviewed the records of 15 patients with metastatic germ cell cancer who underwent aortic resection and replacement during post-chemotherapy retroperitoneal lymph node dissection to determine the morbidity and the therapeutic benefit.Materials and Methods: Between 1970 and 1998, 1,250 patients underwent post-chemotherapy retroperitoneal lymph node dissection. Our retrospective review revealed that 15 patients underwent aortic replacement at that operation.Results: In addition to aortic replacement 11 patients underwent 15 additional procedures, including nephrectomy in 7, vena caval resection in 3, pulmonary resection in 1, small bowel resection in 2, 1 hepatic resection in 1 and L4 vertebrectomy in 1. No patient had necrosis as the only pathological condition. Three patients (20%) had teratoma and 12 (80%) had viable tumor in the retroperitoneal specimen. All 4 patients who underwent post-chemotherapy retroperitoneal lymph node dissection and aortic replacement after induction chemotherapy al... more...

Desmoplastic/spindle cell melanoma is a rare variant of melanoma. A number of factors complicate the diagnosis of desmoplastic/spindle cell melanoma, including the variable absence of a lentiginous component, its spindle cell morphology, and its many morphologic mimics, including scars, malignant peripheral nerve sheath tumor, neurofibroma, atypical fibroxanthoma, and spindled carcinoma. The immunohistochemical confirmation of desmoplastic/spindle cell melanoma may also be difficult, because the majority of tumors are negative for specific melanocytic markers such as HMB-45 and Melan-A, despite their usual expression of S-100 protein. Two new and potentially promising melanocytic markers, microphthalmia transcription factor (MiTF) and melanoma cell adhesion molecule (Mel-CAM), have been shown to be sensitive markers of epithelioid melanoma, but have not been tested in desmoplastic/spindle cell melanoma or in other rare melanocytic neuroectodermal tumors such as clear cell sarcoma. We immunostained 79 tumors (20 desmoplastic/spindle cell melanomas, 10 scars, 10 neurofibromas, 12 malignant peripheral nerve sheath tumors, 10 atypical fibroxanthomas, 10 clear cell sarcomas, 3 melanotic schwannomas, and 4 cellular blue nevi) for MiTF and Mel-CAM. MiTF expression was seen in 11 of 20 desmoplastic/spindle cell melanomas, 0 of 10 scars, 2 of 10 neurofibromas, 0 of 12 malignant peripheral nerve sheath tumors, 1 of 10 atypical fibroxanthomas, 7 of 10 clear cell sarcomas, 3 of 3 melanotic schwannomas, and 3 of 4 cellular blue nevi. Mel-CAM expression was present in 14 of 17 desmoplastic/spindle cell melanomas, 0 of 10 scars, 4 of 10 neurofibromas, 3 of 11 malignant peripheral nerve sheath tumors, 0 of 10 atypical fibroxanthomas, 9 of 10 clear cell sarcomas, 3 of 3 melanotic schwannomas, and 0 of 4 cellular blue nevi. MiTF and Mel-CAM were coexpressed in 6 of 17 desmoplastic/spindle cell melanomas and in no other tumor. Regarding desmoplastic/spindle cell melanoma, scar, neurofibroma, malignant peripheral nerve sheath tumor, and atypical fibroxanthoma, the sensitivity and specificity of MiTF for desmoplastic/spindle cell melanoma were 55% and 91%, respectively. For this same group of tumors, Mel-CAM had a sensitivity of 82% and a specificity of 83%. We conclude that the sensitivity and specificity of MiTF for desmoplastic melanoma equals or exceeds that of such markers as HMB-45 or Melan-A, and that MiTF should be part of the initial immunohistochemical panel for the work-up of such cases. Mel-CAM, while very sensitive, is relatively nonspecific, because it is also expressed in a variety of mesenchymal tumors and carcinomas. Mel-CAM is best reserved for cases morphologically suspected to be desmoplastic/ spindle cell melanoma, in which S-100 is positive and MiTF and other melanocytic markers are negative. These markers may also be helpful in certain other differential diagnoses, such as distinguishing clear cell sarcomas from epithelioid malignant peripheral nerve sheath tumors. more...

Ashish M Kamat, Houston, TX; Sam S Chang, Nashville, TN; Cheryl Lee*, Ann Arbor, MI; Gilad Amiel, Houston, TX; Timothy Beard, Bend, OR; Amr Fergany, Cleveland, OH; R Jeffrey Karnes, Rochester, MN; Venu Menon, Cleveland, OH; Wade Sexton, Tampa, FL; Joel Slaton, Oklahoma City, OK; Robert Svatek, San Antonio, TX; Shandra Wilson, Denver, CO; Lee Techner, Lexington, MA; Richard Bihrle, Michael Koch, Indianapolis, IN; Gary D Steinberg, Chicago, IL more...

Purpose: We determined whether standardized care patterns developed with a collaborative care methodology can be applied successfully across all patient groups with favorable effects on cost and quality.Materials and Methods: We retrospectively analyzed financial and clinical outcomes in 109 radical retropubic prostatectomy and 47 radical cystectomy cases. Patients older than 70 years and/or with an American Society of Anesthesiology status of 3 or greater were compared to younger, healthier patients undergoing these procedures.Results: Standardized care patterns resulted in favorable financial and clinical outcomes in high and low risk patient groups. The only apparent difference was an increased need for rehospitalization after discharge for patients undergoing radical prostatectomy with a high American Society of Anesthesiology status.Conclusions: Standardized care patterns developed with a collaborative care methodology provide a high quality, cost-efficient approach to medical care. This meth... more...

Purpose: We examined further whether the injury or method of management is responsible for impotence and incontinence after immediate realignment of prostato-membranous urethral disruptions.Materials and Methods: A total of 20 patients with complete urethral disruptions treated with immediate realignment (group 1) was compared to 12 with partial or complete injuries treated with retrograde catheterization alone (group 2). Followup status was obtained by patient questionnaire or telephone interview.Results: Of the patients 83 percent in group 1 and 80 percent in group 2 are continent, and 76 percent and 70 percent, respectively, regained erections suitable for sexual intercourse.Conclusions: The results suggest that impotence and incontinence in this setting are the result of the injury and not of attempts at immediate surgical management. more...

The prognostic significance of perineural invasion in radical prostatectomy specimens is uncertain. We evaluated the relationship between perineural invasion and other pathological characteristics in whole mount radical retropubic prostatectomy specimens as well as prostate specific antigen (PSA) recurrence postoperatively.Between 1999 and 2003, 364 consecutive patients were treated with radical prostatectomy for localized prostate cancer. Radical prostatectomy specimens were processed by the whole mount technique. The relationship of perineural invasion and various clinicopathological characteristics to PSA recurrence was analyzed.Perineural invasion was present in 287 specimens (79%). Specimens with perineural invasion were associated with smaller prostate weight (p0.0001), greater pathological stage (p0.0001), larger tumor volume (p0.0001), higher Gleason score (p0.0001), a higher incidence of extraprostatic extension (p0.0001) and seminal vesicle invasion (p = 0.02), and a higher positive surgical margin rate (p = 0.01). Perineural invasion did not correlate with preoperative PSA (p = 0.96), lymph node metastases (p = 0.35), multifocality (p = 0.21), high grade prostatic intraepithelial neoplasia (p = 0.12) or PSA recurrence (p = 0.24).While perineural invasion in the radical prostatectomy specimen significantly correlated with multiple adverse pathological factors, it did not predict which patients will have early PSA recurrence following radical prostatectomy. more...