Metastatic carcinomas involving the testis and testicular adnexa occur only rarely. It is even more unusual when the metastasis is associated with an occult primary tumor. In these circumstances, the correct diagnosis may not be made. The purpose of this report is to describe an asymptomatic primary adenocarcinoma of the cecum that presented as a testicular adnexal mass and to demonstrate that histochemical, immunohistochemical, and ultrastructural features may be of great value in arriving at the diagnosis of metastatic adenocarcinoma.

Objective: To assess the value of adrenal mass absolute growth, growth rate, and percentage growth rate on serial imaging for distinguishing benign from malignant adrenal masses.Methods: We retrospectively reviewed the Cleveland Clinic medical record data on 136 adrenalectomies or biopsies in 132 patients with 2 imaging studies performed more than 2 months apart (during 1997 to 2008).Results: There were 111 benign (81.6%) and 25 malignant (18.4%) adrenal masses. With use of receiver operating characteristic curve analysis, all 3 aforementioned growth measures showed similar levels of discrimination for the entire study group as well as for the subgroups with 3 to 12 months of follow-up (n = 75 masses) and noncontrast computed tomography Hounsfield units >10 or not reported (n = 111 masses). After adjustment for other factors, the 3 growth measures remained statistically significant predictors of a malignant tumor. The absolute growth cutoff value of 0.8 cm had the highest sum of sensitivity and specificity of 72% and 81.1%, respectively. We could not identify an adrenal mass growth cutoff value to provide 100% sensitivity or specificity to confirm or exclude the presence of a malignant lesion. In 3 patients with metastatic lesions, no growth or a decrease in mass size during a period of 4 to 36 months was observed.Conclusion: In this study, the largest with surgical histopathology findings as the "gold standard" for diagnosis, change in adrenal, mass size was a significant predictor of a malignant tumor. Nevertheless, we could not identify an adrenal mass growth cutoff value for reliable confirmation or exclusion of a malignant lesion. Change in adrenal mass size should be used in conjunction with other imaging and clinical characteristics when surgical resection is being considered. (Endocr Pract. 2010;16:577-587)

PURPOSE:The value of pathological reinterpretation of tissue slides has long been questioned. At the Cleveland Clinic subspecialization in genitourinary pathology began in 2003 and has been maintained. We evaluate the role of second review on transurethral bladder tumor resection pathology slides before and after subspecialization and potential impact on treatment.MATERIALS AND METHODS:Transurethral bladder tumor resection specimens from 78 and 116 patients with bladder cancer in 2002 and 2004, respectively, were reviewed. Initial surgical pathology reports from institutions outside the Cleveland Clinic were compared with review report by a pathologist with genitourinary pathology specialization (HSL). Those cases with differences in diagnosis or staging were then evaluated by a urologist (JSJ) considering current standards of care.RESULTS:The reinterpretation differed substantially from the initial report in 26 of 78 cases (33.3%) in 2002 and in 31 of 116 (26.7%) in 2004 (p = 0.3), resulting in a possible impact on management in 28.2% (22 of 78) in 2002 and 23.3% (27 of 116) in 2004 (p = 0.54). In each year 4 cases diagnosed with bladder cancer elsewhere were determined to have no malignancy. The majority of discrepancies related to the presence of carcinoma in situ in 2002 and to the presence or absence of muscularis propria and/or muscle involvement by carcinoma in 2004.CONCLUSIONS:Second review of transurethral bladder tumor resection specimens shows differences of interpretation in 26.7% to 33.3% of cases, which is sufficient to alter management. There was no significant difference in the rate of discrepancies before and after genitourinary pathology subspecialization. Referral centers must assume responsibility for establishing the diagnosis before consultation and/or therapy.

The independent prognostic importance of microscopic bladder neck involvement by prostate cancer in radical prostatectomy is questionable. We studied a cohort of 1845 patients to determine the significance of microscopic bladder neck involvement. Bladder neck involvement was defined as prostate cancer present within the coned bladder neck. We further categorized the cases as ‘true bladder neck involvement’ and ‘false bladder neck involvement.’ True bladder neck involvement required prostate cancer within thick smooth muscle bundles without intermixed benign prostatic glands. False bladder neck involvement was characterized by prostate cancer intermixed with benign prostatic glands. Bladder neck involvement was analyzed in relation to preoperative serum prostate-specific antigen (PSA) level, extraprostatic extension, seminal vesicle involvement, positive surgical margin, lymph node involvement, radical prostatectomy Gleason score, and tumor volume. Of the 90 patients (4.9%) with microscopic bladder neck involvement, 63 were further classified as true bladder neck involvement and 27 as false bladder neck involvement. In univariate model, both types of bladder neck involvement ( P <0.001), true ( P <0.001), and false ( P =0.040), were significantly associated with increased PSA-recurrence risk compared to bladder neck negative cases. In multivariate model the PSA-recurrence relative risk associated with bladder neck involvement (true or false) was not a significant independent prognostic factor. Extraprostatic extension, seminal vesicle involvement, positive surgical margin, lymph node involvement, PSA, and Gleason score were significant independent predictors of PSA recurrence. The time to biochemical recurrence in patients with bladder neck involvement was similar to that of pT2 with positive surgical margin or pT3a with negative surgical margin patients (Kaplan–Meier curves). Bladder neck involvement was associated with other adverse pathologic features, but was not an independent predictor of PSA recurrence. In view of the previous and current data, the staging system for bladder neck involvement should be revised and patients may be best categorized as having pT3a disease.

OBJECTIVES To examine the relationship between preoperative prostate-specific antigen (PSA) and pathologic characteristics of the prostate gland and prostate cancer at radical prostatectomy in patients with clinically localized disease in the early (1993 to 1998) and late (1999 to 2004) PSA eras.METHODS From January 1, 1993 to December 31, 2004, 2067 patients aged 40 to 80 years with clinically localized prostate cancer underwent radical prostatectomy without neoadjuvant therapy at the Cleveland Clinic. The correlation among the preoperative PSA level, prostate volume, percentage of Gleason pattern 4/5, surgical Gleason score, and cancer volume was calculated using Pearson's and Spearman's tests for the early (1993 to 1998) and late (1999 to 2004) PSA eras. Logistic regression analyses were performed to identify independent predictors of the percentage of Gleason pattern 4/5 and cancer volume during each era.RESULTS In both eras, the PSA level correlated positively with the percentage of Gleason pattern 4/5, surgical Gleason score, and prostate volume, with nearly identical r values. The PSA level also correlated with the cancer volume in the late PSA era (the only era for which cancer volume data were available). In the multivariate model, biopsy Gleason score, clinical T stage, and PSA level were independent predictors of percentage of Gleason pattern 4/5 in both eras and of cancer volume in the late PSA era.CONCLUSIONS Even in the late PSA era, the preoperative PSA level has retained its predictive value for the percentage of Gleason pattern 4/5 and cancer volume. The PSA level continues to have prognostic value for men with clinically localized prostate cancer treated by radical prostatectomy.

Objectives. To evaluate the contemporary indications and outcome after partial nephrectomy for renal urothelial cancer. Partial nephrectomy is an established treatment for renal cell cancer but its use for renal urothelial tumors has been studied less extensively.Methods. Records were reviewed for patients undergoing partial nephrectomy for renal urothelial tumors between January 1990 and December 2001. Partial nephrectomy was selected for those with a solitary kidney, chronic renal insufficiency, or bilateral synchronous tumors. Partial nephrectomy was performed according to the principles of partial nephrectomy. Follow-up included ultrasonography, intravenous urography, computed tomography, metastatic workup, and renal function evaluation.Results. This study included 12 patients (12 kidneys, 10 solitary) with a mean age of 68.5 +/- 21 years and a mean follow-up of 40.8 +/- 32 months. The pathologic T stage was Tis in 1 patient, T1 in 3, T2 in 2, and T3 in 6 patients. Of the 12 patients, 6 had negative surgical margins, and 4 of the 12 patients (30%) were tumor free after a mean follow-up of 57.7 months. Of the 6 patients with positive surgical margins (Stage T1 in 2 and T3 in 4), 1 developed recurrence and 3 developed metastasis; 4 died after a mean of 31.3 months. Overall recurrence was seen in 5 (42%) and progression (metastasis) in 6 (50%) patients. Of the 12 patients, 6 were alive, 4 of them were well (mean serum creatinine 1.83 mg/dL) at 62 months of follow-up. Two patients required dialysis. The overall long-term survival rate was 50%.Conclusions. Partial nephrectomy for renal urothelial tumors is feasible and should be considered in a select population. Dialysis or renal replacement can be delayed or avoided in most of these patients, but strict surveillance remains mandatory.

Objectives. To report a series of patients. with mucinous (colloid) adenocarcinoma (MC) at prostatectomy who were treated at a single institution from 1987 to 2005. MC is a rare form of prostate cancer reported in some cases to have a more aggressive clinical course than conventional adenocarcinoma (AC).Methods. Radical prostatectomy specimens with mucinous features were identified from a database of 3613 consecutive patients. Each case was reviewed again by a single pathologist who confirmed the diagnosis of MC in 14 patients. MC was defined by the presence of pools of extracellular mucin in more than 25% of the tumor. Eighteen additional cases were identified in which the mucinous component occupied only a small portion of the tumor and were referred to as AC with focal mucin (AFM). The biochemical and overall survival of 26 patients with MC or AFM who had completed >= 6 months of follow-up was analyzed using Kaplan-Meier estimates.Results. No patients with MC or AFM died of disease, and 11 (91.7%) of 12 patients with MC and 9 (64.3%) of 14 patients with AFM were clinically and biochemically free of disease. No significant difference was found in biochemical recurrence or overall survival between those with MC or AFM and a matched group of patients with AC.Conclusions. We report what we believe to be the largest published series of cases of MC (n = 14) with a median overall follow-up of 6.4 years. MC appears to behave clinically in a similar fashion to AC, with no statistically significant difference in biochemical failure or survival. (c) 2006 Elsevier Inc.

Radiological characterization of an adrenal tumor as adenoma may decrease the need for follow-up imaging studies, biopsies, and unnecessary adrenalectomies. We retrospectively reviewed 299 adrenalectomies in 290 patients at Cleveland Clinic Foundation over a recent 5-yr period to assess the value of noncontrast Hounsfield units (HU) in characterizing whether an adrenal mass is adenoma or nonadenoma. The mean (+/- SD) HU value for the adrenocortical adenoma/hyperplasia group was 16.2 +/- 13.6 and significantly lower (P < 0.0001) than primary adrenocortical cancers (36.9 +/- 4.1), metastases (39.2 +/- 15.2), and pheochromocytomas (38.6 +/- 8.2). The sensitivity and specificity for 10- and 20-HU cutoff values to differentiate adenomas/hyperplasias from nonadenomas were 40.5 and 100% and 58.2 and 96.9%, respectively. The size of the adrenal tumor had less value with only 40.7 and 81.3% sensitivity and 94.7 and 61.4% specificity for 2- and 4-cm cutoff values. A combination of less than or equal to 4-cm adrenal mass size and noncontrast computed tomography HU less than or equal to 20 had 42.1% sensitivity and 100% specificity. Our study, the largest with surgical histopathology as the gold standard for diagnosis, supports a noncontrast computed tomography attenuation value of 10 HU as a safe cutoff value to differentiate adrenal adenomas/hyperplasias from nonadenomas.

You have accessJournal of UrologyModerated Poster, Wednesday, May 25, 2005, 3:30 - 5:30 pm1 Apr 20051674: Low-Volume Prostate Cancer is Not Necessarely Pathologically and Clinically Insignificant Ming Zhou, Ehab El-Gabry, Marek Skacel, Jonathan Myles, Howard S. Levin, Alwyn M. Reuther, Eric A. Klein, and Cristina Magi-Galluzzi Ming ZhouMing Zhou More articles by this author , Ehab El-GabryEhab El-Gabry More articles by this author , Marek SkacelMarek Skacel More articles by this author , Jonathan MylesJonathan Myles More articles by this author , Howard S. LevinHoward S. Levin More articles by this author , Alwyn M. ReutherAlwyn M. Reuther More articles by this author , Eric A. KleinEric A. Klein More articles by this author , and Cristina Magi-GalluzziCristina Magi-Galluzzi More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)35796-3AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "1674: Low-Volume Prostate Cancer is Not Necessarely Pathologically and Clinically Insignificant." The Journal of Urology, 173(4S), p. 454 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 173Issue 4SApril 2005Page: 454 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Ming Zhou More articles by this author Ehab El-Gabry More articles by this author Marek Skacel More articles by this author Jonathan Myles More articles by this author Howard S. Levin More articles by this author Alwyn M. Reuther More articles by this author Eric A. Klein More articles by this author Cristina Magi-Galluzzi More articles by this author Expand All Advertisement PDF downloadLoading ...

Purpose/Objective: The primary purpose of this study was to analyze the relationship between the proportion of positive cores from prostate biopsies (%PosCores) and volume of cancer determined from radical prostatectomy (RP) specimens. The secondary purpose was to determine the importance of %PosCores as a predictor of early biochemical relapse after definitive radiotherapy (RT). Materials/Methods: %PosCores was defined as the number of positive cores divided by the total number of collected cores. A total of 103 RP patients at the Cleveland Clinic Foundation in 2001 had complete pathologic information from the prostate biopsy specimens. None of the 103 cases received neoadjuvant androgen deprivation (AD). The %PosCores was ≤30% in 55% of patients, >30%-≤60% in 34%, and >60% in 11%. The volume of cancer in the prostatectomy specimens was classified as low (≤0.5 cc), medium (>0.5 to ≤2 cc), or high (>2 cc). A second analysis was performed on 218 stage T1-T2 prostate cancer patients treated with RT at the Cleveland Clinic Foundation from 1998 to 2001 who had complete information on %PosCores. The median follow-up in the RT cohort was 30 months (minimum: 12 months). None of the RT patients received AD for ≥6 months. The median RT dose was equivalent to 83 Gy (range: 70 to 83 Gy). The %PosCores in the RT cohort was ≤30% in 54% of patients, >30%-≤60% in 33%, and >60% in 13%. For the 218 RT cases, the T-stage distribution was T1-T2A in 90% of patients and T2B-T2C in 10%. The distribution by initial PSA levels (iPSA) was ≤10 in 67% of patients and >10 in 33%. The distribution by biopsy Gleason score (bGS) was ≤6 in 53% of patients and ≥7 in 47%. The analysis endpoint was biochemical relapse-free survival (bRFS). The ASTRO definition of biochemical relapse was used. Results: In the 103 RP cases, the overall distribution of low, medium and high cancer volumes was 32%, 50% and 18%. The %PosCores correlated significantly with prostate cancer volume in the RP specimens. For %PosCores ≤30%, the distribution of low, medium and high cancer volumes was 44%, 44% and 12%, respectively. For %PosCores >30%-≤60%, the distribution of low, medium and high cancer volumes was 17%, 66%, and 17%, respectively. However, for %PosCores >60%, the distribution of low, medium and high cancer volumes was 18%, 27% and 55%, respectively (Chi Square p=0.001). On multivariate analysis, only %PosCores (continuous variable) was an independent predictor of high-volume cancer (p=0.019). All other factors were not (T-stage, iPSA, and bGS). For the 218 RT cases, the 3-year bRFS rates for %PosCores ≤30%, >30%-≤60%, and >60% were 100%, 94% and 76%, respectively (p=0.002). On multivariate analysis, %PosCores (continuous variable) was the only independent predictor of biochemical failure (p=0.020). All other factors were not (T-stage, iPSA, bGS and AD). Conclusions: The %PosCores is a predictor of high-volume cancer. The 10 to 15% of patients with localized prostate cancer with %PosCores >60% have a 55% probability of having high-volume cancers. Patients with a high %PosCores have a high rate of early failures after radiotherapy. Although these tumors might be associated with a higher rate of metastatic disease (which could explain early failures), it is also possible that these early biochemical failures reflect the inability of current radiation doses and techniques to eradicate high-volume cancers. If treated with radiotherapy, patients with a large proportion of positive core biopsies should be considered ideal candidates for intraprostatic boosting with techniques such as IMRT or brachytherapy.

Prostate-specific antigen (PSA) screening has resulted in a profound clinical stage migration. Extracapsular extension (ECE) presents a poor prognosis after radical prostatectomy (RP). In this study the trends in rate of ECE for cancers detected by PSA screening between 1987, when PSA screening became routine in the United States, and 2001, were examined. The clinical outcome of patients (total 1505; 888 clinical Tlc, 614 clinical T2, and 3 clinical T3) with prostate cancer diagnosed by PSA screening and treated with RP without neoadjuvant hormonal therapy was analyzed. The primary outcome variable was ECE rate with respect to year of treatment for a given tumor stage, preoperative PSA level, biopsy Gleason score, and surgical Gleason score. Logistic regression analysis was used to identify predictors of ECE. Biochemical relapse-free survival (bRFS) by year of treatment was analyzed by Kaplan-Meier Curve. Rate of ECE decreased from 65.8 to 25.2% during the 15-year study duration. Multivariate analysis of clinical tumor stage, age, preoperative serum PSA level, and Gleason score confirmed that year of treatment was an independent predictor of ECE. Six-year bRFS rates (by years of treatment) were 75.1% for 1987 to 1994 and 82.6% for 1995 to 2001 (P-value = 0.0022). PSA screening has resulted in a downward pathological stage migration. These observations demonstrate improved biochemical failure rates in more recently treated patients.