Objective: To determine whether prostate image reporting and data system (PIRADS) 3 lesions as assessed by a 3T multiparametric magnetic resonance imaging (MRI) represent clinically significant prostate cancer. Method: A retrospective review was performed on a series of consecutive patients who underwent MRI guided biopsy of the prostate for clinical suspicion of prostate cancer between January 2013 and March 2014. Demographic, clinical, MRI and biopsy data were reviewed and compared. The same 3T MRI without the use of an endo-rectal coil was employed to assess each patient, obtaining high resolution T2 weighted images, diffusion weighted imaging and dynamic contrast enhancement. The MRI data was sent to Dynacad software for analysis. A single experienced radiologist reported all the studies from this series using a modified PIRADS scoring system. Subsequently, all the lesions marked PIRADS 3 or above were targeted with 18G core biopsy using DynaTrim in-gantry MRI guidance system. Needle position targeting the lesion was recorded prior to each biopsy. All core biopsy samples were sent to one of two pathology laboratories where they were processed and reported as per the International Society of Urological Pathology protocols. Results: One hundred and eighteen patients comprising a total of 215 lesions were reviewed. Amongst this cohort, 92 PIRADS 3 lesions were identified and biopsied. The mean age of patients in this cohort was 62.6 years. Median prostate specific antigen (PSA) was 6.5 ng/ml and median prostate size was 78.4 ml. Eightysix (93.5%) of biopsied PIRADS 3 lesions were benign and 6 (6.5%) lesions were found to be malignant. Of these 6 malignant lesions, 4 (66%) were Gleason score 6 (3 + 3) and 2 (33%) were Gleason score 7 (3 + 4). Of the 86 non-malignant lesions, 1 (1.2%) represented high-grade prostate intraepithelial neoplasia and 2 (2.4%) represented atypical small acinar proliferation. PIRADS 3 lesions within the peripheral zone were more likely to be associated with malignant disease compared with lesions identified within the transition zone (10.8 vs. 3.8%). Those with malignant disease had a higher median PSA (8.1 vs. 6.4 ng/ml) and higher median PSA density (0.12 vs. 0.08) than those without malignant disease. Those with benign pathology had a higher prevalence of inflammation (31.4 vs. 16.7%). As per Epstein's criteria, 4 (4.3%) of the biopsied lesions represented clinically significant disease. Conclusion: We have demonstrated in our series, that prostate lesions characterized on a 3T multiparametric MRI examination of the prostate as PIRADS 3, according to the current prevalent scoring systems, are associated with a low likelihood of the presence of clinically significant prostate cancer.
Objective: To compare the immediate postoperative outcomes of patients with benign prostatic hyperplasia undergoing Holmium laser enucleation of the prostate (HOLEP) with and without full anticoagulation or antiplatelet therapy at the time of surgery. Materials and Methods: A retrospective review was performed on a series of consecutive patients undergoing HOLEP at our institution by a single surgeon from February 2004 to September 2010. Demographic, surgical, pathological and outcome data were collected. Two cohorts were identified on the basis of antithrombotic therapy at the time of surgery. Patients who continued on aspirin, aspirin/dipyridamole, clopidogrel and warfarin throughout the surgery were included in the antithrombotic cohort. Univariate analysis was performed to determine differences in outcomes between the 2 cohorts. Results: Total 125 consecutive patients underwent HOLEP with 52 patients on antithrombotic therapy at the time of surgery and 73 patients were not on antithrombotic therapy during surgery. Patients in the antithrombotic group were older (75.1 ±7.5 vs. 71.7 ± 8.3 years; p = 0.02) and had a higher median ASA physical status (3 (3-3) vs. 2 (2-3), p < 0.0001). The mean operating time and median specimen volume were not significantly different between the 2 cohorts. The median length of stay (2 (1-3) vs. 1 (1-2) d, p = 0.014) was longer in the antithrombotic cohort. The transfusion rate (7.7 vs. 0%, p = 0.028) was predictably higher in the antithrombotic cohort. No patients required re-operation for bleeding. Conclusions: The use of HOLEP in patients on antithrombotic therapy is safe despite the higher surgical risk profile of that particular patient population and the potential increased risk for significant bleeding.
HighlightsADCratio is a reliable and reproducible tool in quantification of diffusion restriction for clinically significant PCa foci.Comparing an experienced and a new MRI reader, Inter-reader reliability in the calculation of ADCratio was excellent.ADCratio has potential to replace the current practice of visual analysis of ADCtumour reduction, and provide an objective tool.
Clear cell papillary renal cell carcinoma (CCP-RCC) is a recently described, relatively uncommon variant of renal cell carcinoma (RCC) with a reported incidence of 4.1%. Thought to only arise in those with end stage renal disease, CCP-RCC is increasingly identified in those without renal impairment. CCP-RCCs have unique morphologic, genetic, and immunohistochemical features distinguishing them from both conventional clear cell renal cell carcinomas and papillary renal cell carcinomas. Immunohistochemically, these tumors are positive for CK7 and negative for CD10 and racemase. This is in contrast to conventional cell renal cell carcinomas (CK7 negative, CD10 positive) and papillary cell carcinomas (CK7, CD10, and racemase positive). These tumours appear to be indolent in nature, with no current documented cases of metastatic spread. We present the case of a 42-year-old female who presented with an incidental finding of a renal mass that on a core biopsy was reported as clear cell carcinoma, Fuhrman grade 1. She subsequently underwent a radical nephrectomy and further histological examination revealed the tumor to be a clear cell papillary renal cell carcinoma, Fuhrman grade 1.
Urachal mucinous cystic tumours are rare pathological findings with only 23 previously reported cases in the literature. We present the case of a 54-year-old man with an incidentally found urachal mucinous cystic tumour laparoscopically excised. With its known potential to cause pseudomyxoma peritonei, complete surgical excision is important. Long-term cystoscopic and radiological surveillance is also required.
Fig. 3. Image from histologic examination showing large foreign body giant cell reaction, and central plant-like material surrounded by palisaded histiocytes and multinucleate giant cells.
Inflammatory myofibroblastic tumor is a rare but benign clinical entity. Its ability to mimic malignancy poses a diagnostic challenge. Here, we report the first case in Australia, of inflammatory myofibroblastic tumor in the bladder in a 40-year-old male, removed via transurethral resection.
Ectopic ureteric insertion to a seminal vesicle cyst associated with renal dysplasia is a rare anomaly. [1][2][3] We present the case of a patient with urosepsis on a background of right-sided renal dysplasia, ectopic megaureter with insertion into an ipsilateral seminal vesicle cyst with subsequent spontaneous ureterovesical fistula formation that required a semi-elective laparotomy. This case serves to highlight the embryology and anatomy of ectopic ureteric insertion to a seminal vesicle cyst, its complications and the benefits of T3MRI in defining the abnormal anatomy.A 62-year-old male Caucasian was transferred from a regional hospital with urosepsis following office-based transrectal aspiration of a pelvic cyst identified on trans-rectal ultrasound examination. The patient was immunosuppressed with etanercept for treatment of ankylosing spondylitis.Physical examination revealed the patient having a large, asymmetric and tender pelvic cystic mass in the region of the right prostate lobe. Initial CT scan suggested a right ectopic megaureter with seminal vesicle insertion and associated renal dysplasia.It was noted that the patient also developed spontaneous purulent discharge into his indwelling catheter with corresponding improvement in his symptoms, suggesting a spontaneous drainage, decompression and fistula formation of the infected right upper urinary tract to the bladder.The patient improved further with broad-spectrum intravenous antibiotics and catheter drainage. He subsequently underwent T3MRI of his urinary tract which confirmed the diagnosis of right-sided renal dysplasia, ectopic megaureter inserting into an ipsilateral seminal vesicle cyst with spontaneous uretero-vesical fistula formation (Figs 1,2).Unfortunately the patient's infection was difficult to control due to his immunosuppressant use and the decision was made to proceed to semi-elective laparotomy and open right nephro-ureterovesicalectomy and fistula repair once the local infection and inflammation completely resolved.Cystoscopy performed prior to the laparotomy showed absence of the native right ureteric orifice. A fistulous opening was demonstrated to lead to the ectopic right ureter on retrograde pyelogram. The existing local pelvic inflammation and adhesions made positive identification of the seminal vesicle cyst difficult intraoperatively.The histology of the resected specimen revealed a completely atrophic right kidney with fibrosis, thyroidisation of tubules, cystic change and haemosiderin laden macrophages with no glomeruli identified. The ureter measured 15 mm across with generalized inflammatory changes. The distal ureteric margin had dense fibrosis with large numbers of haemosiderin laden macrophages and denuded, haemorrhagic urothelium -features consistent with a fistulous tract. The seminal vesicle cyst could not be identified in the submitted specimen (Fig. 3).Embryological development of the ureter starts as an outgrowth of the distal mesonephric duct towards the end of the fourth week of gestation. This ureteric bud d...
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