Untreated Gleason Grade Progression on Serial Biopsies during Prostate Cancer Active Surveillance: Clinical Course and Pathological Outcomes.

PURPOSE: We describe the outcomes of patients with low risk localized prostate cancer who were upgraded on a surveillance biopsy while on active surveillance and evaluated whether delayed treatment was associated with adverse outcome. MATERIALS AND METHODS: We included men in the study with lower risk disease managed initially with active surveillance and upgraded to Gleason score 3+4 or greater. Patient demographics and disease characteristics were compared. Kaplan-Meier curve was used to estimate the treatment-free probability stratified by initial upgrade (3+4 vs 4+3 or greater), Cox regression analysis was used to examine factors associated with treatment and multivariate logistic regression analysis was used to evaluate the factors associated with adverse outcome at surgery. RESULTS: The final cohort comprised 219 men, with 150 (68%) upgraded to 3+4 and 69 (32%) to 4+3 or greater. Median time to upgrade was 23 months (IQR 11-49). A total of 163 men (74%) sought treatment, the majority (69%) with radical prostatectomy. The treatment-free survival rate at 5 years was 22% for 3+4 and 10% for 4+3 or greater upgrade. Upgrade to 4+3 or greater, higher prostate specific antigen density at diagnosis and shorter time to initial upgrade were associated with treatment. At surgical pathology 34% of cancers were downgraded while 6% were upgraded. Cancer volume at initial upgrade was associated with adverse pathological outcome at surgery (OR 3.33, 95% CI 1.19-9.29, p=0.02). CONCLUSIONS: After Gleason score upgrade most patients elected treatment with radical prostatectomy. Among men who deferred definitive intervention, few experienced additional upgrading. At radical prostatectomy only 6% of cases were upgraded further and only tumor volume at initial upgrade was significantly associated with adverse pathological outcome.

Prevalence of human herpesvirus-8 salivary shedding in HIV increases with CD4 count.

Human herpesvirus-8 (HHV-8) is the etiologic agent of Kaposi's sarcoma (KS), which occurs in epidemic form in human immunodeficiency virus(HIV)-infected individuals. Saliva is the only mucosal fluid in which infectious HHV-8 has been identified, although factors associated with HHV-8 salivary shedding remain unclear. Our study performed PCR analysis for HHV-8 DNA in saliva (and other body fluids) in 66 HIV- and HHV-8-co-infected women without KS so that we could examine predictors for HHV-8 DNA detection. CD4 count was the most significant predictor of HHV-8 salivary shedding, with increased prevalence of HHV-8 salivary DNA at higher CD4 counts. The odds of salivary HHV8 shedding at CD4 counts > = 350 cells/microL was 63 times the odds of shedding at CD4 < 350 (95%CI, 1.3-3078), with an increase in effect size when the analysis was restricted to those with a CD4 nadir > 200. Analysis of these data suggests an increased potential for HHV-8 transmission early in HIV infection, with implications for HHV-8 prevention.

Accuracy of self-reports of acquired immunodeficiency syndrome and acquired immunodeficiency syndrome-related conditions in women.

To investigate the validity of self-reported acquired immunodeficiency syndrome (AIDS) among women enrolled in a prospective study of human immunodeficiency virus (HIV) infection, the authors compared the self-reported occurrence of AIDS-specific diagnoses with AIDS diagnoses documented by county AIDS surveillance registries. Also examined was the association between participant characteristics and the validity of self-reports. Among the 339 HIV-infected participants in the Northern California Women's Interagency HIV Study between October 1994 and September 1998, 217 reported having been given a diagnosis of AIDS. Of these 217 women, 157 (72%) were listed in the registry as having AIDS. Among the specific AIDS-related conditions reported by three or more women, the sensitivity was highest for tuberculosis (100%), CD4 cell count less than 200 (84%), Mycobacterium avium complex (73%), and Pneumocystis carinii pneumonia (69%), and the positive predictive value was highest for CD4 cell count less than 200 (75%). Among all reported AIDS diagnoses, the kappa statistic was highest for cryptococcosis (0.67) and CD4 cell count less than 200 (0.57). The only statistically significant participant characteristic associated with inaccurate reporting of an AIDS diagnosis was being a current cigarette smoker (adjusted odds ratio = 2.57, 95% confidence interval: 1.17, 5.64). Overall, self-reporting of any AIDS-related condition is fairly accurate, but there is great variability in the accuracy of specific conditions.

Factors associated with incident self-reported AIDS among women enrolled in the women's interagency HIV study (WIHS). WIHS Collaboratorive Study Group.

We evaluated factors associated with incident self-reported AIDS diagnoses among HIV-infected women in the Women's Interagency HIV Study (WIHS). Baseline information included age, race/ethnicity, HIV risk category, site of enrollment, years of education, cigarette smoking, CD4 cell count, and HIV viral load. Baseline and follow-up data on self-reported AIDS were analyzed using chi-square, Kaplan-Meier, and Cox proportional hazard models. Among the 1397 HIV-infected women who reported being free of clinical AIDS at baseline, 335 women (24%) reported an incident AIDS diagnosis during follow-up. In stratified Kaplan-Meier analyses, the development of self-reported AIDS was significantly associated with baseline CD4 cell count and viral load (p<0.01). In multivariate Cox proportional hazard analyses, women were statistically more likely to report AIDS if they had CD4 cell counts below 195 cells/mm3 (p<0.01), HIV RNA >4000 copies/ml (p<0.01), were current smokers (p<0.01), and had "no identifiable risk" for acquisition of HIV (p = 0.03). Self-reports of a clinical AIDS diagnosis may not always be accurate, but laboratory markers of HIV disease indicate that those women who self-report such diagnoses have greater immunodeficiency and a higher viral load when compared with those who report no AIDS-defining diagnoses.

Impact of the ovulatory cycle on virologic and immunologic markers in HIV-infected women.

An individual's sex influences plasma human immunodeficiency virus type 1 (HIV-1) RNA level and rate of CD4 cell decline, but the mechanism for this effect is currently unknown. To determine the effect of the ovulatory cycle on HIV-1 RNA level and lymphocyte subsets in HIV-infected women, blood specimens were obtained weekly from 14 women infected with HIV. Participants reported regular menses and were not using hormonal medications or narcotics. The occurrence of ovulation was verified by use of endocrine criteria. Ovulation occurred in 10 of the 14 women. Among women who ovulated, median HIV-1 RNA level fell by a median of 0.16 log10 from the early follicular phase to the midluteal phase (P=.03, Wilcoxon signed-rank test). When women who did not ovulate were included in the analysis, no significant fluctuation in plasma HIV RNA level was identified. Thus, the ovulatory cycle influenced circulating HIV-1 RNA levels, a finding that is plausible because of the known effect of sex hormones on lymphocyte function and cytokine production.

The prevalence of serum antibody to human herpesvirus 8 (Kaposi sarcoma-associated herpesvirus) among HIV-seropositive and high-risk HIV-seronegative women.

OBJECTIVE: To determine the prevalence of human herpesvirus 8 (HHV-8) seropositivity among women who are known to be infected with human immunodeficiency virus type 1 (HIV-1) or who are at high risk for HIV infection. DESIGN: A cross-sectional and blinded study of the prevalence of serological reactivity to HHV-8 infection as determined by an indirect immunofluorescence assay using nuclei from cells latently infected with HHV-8. Data and specimens were collected at baseline assessments of a longitudinal natural history cohort study. SETTING: Four San Francisco Bay Area outpatient HIV specialty clinics participating in the cohort study. PATIENTS: A total of 387 participants in the Women's Interagency HIV Study whose HIV infection status was documented and serum was available in a local specimen repository. MAIN OUTCOME MEASURE: Serological reactivity to HHV-8. RESULTS: Serological reactivity to latent HHV-8 antigens was uncommon among study participants: 13 (3.4%) demonstrated serum antibodies. HHV-8 reactivity was more common among HIV-infected women; 12 (4.0%; 95% confidence interval [CI], 2.1%-6.9%) of the 302 HIV-infected participants vs 1 (1.2%; 95% CI, 0.03%-6.4%) of the 84 HIV-uninfected participants were seropositive for HHV-8, though the difference did not attain statistical significance (odds ratio=3.43; 95% CI, 0.49-148.6). Two of the HIV-infected women had Kaposi sarcoma lesions and both were seropositive. CONCLUSIONS: The prevalence of HHV-8 seropositivity among the group of HIV-infected women was dramatically lower than that recently reported among HIV-infected homosexual and bisexual men (30%-35%). This finding parallels the lower prevalence of Kaposi sarcoma among women in contrast to men with HIV infection. These data further extend the correlation of HHV-8 serological reactivity with risk of Kaposi sarcoma and are consistent with an important role for HHV-8 infection in development of Kaposi sarcoma.

Aneurysmal bone cysts of the spine. Report of 17 cases.

Seventeen cases of aneurysmal bone cyst of the spine are reported. Clinical manifestations, methods of investigation, differential diagnosis, treatment, and pathogenesis are discussed. The condition is essentially a benign lesion, affects a young age group, and grows rapidly, often producing a paravertebral mass. Occasionally it becomes acutely exacerbated, causing irreversible damage to the spinal cord. For these reasons, prompt diagnosis and timely treatment are important. Excision of the lesion is the treatment of choice but, if not feasible, thorough curettage and radiotherapy not exceeding 2000 rads are indicated. With a two-stage operation, excision of the lesion is often possible, and the stability of the vertebral column is assured with bone-graft fusions.

Aneurysmal bone cyst of the skull.

Aneurysmal bone cysts rarely affect the skull. Thirty-six cases including four reported in this paper are reviewed. The condition usually affects children and young adults and progresses rapidly. It may result in raised intracranial or intraorbital pressure. Complete excision of the mass is the treatment of choice, but if not feasible curettage followed by low dose radiotherapy is effective. As the prognosis in this condition is good, prompt diagnosis and early treatment are of utmost importance.

Monostotic fibrous dysplasia of the cranial bones: report of fourteen cases.

Polyostotic fibrous dysplasia affects many bones of the skeleton and usually on one side only. In monostotic variety only one bone is affected. The condition which usually starts in early childhood is at first active, gradually becomes quiescent and finally with termination of skeletal growth becomes inactive and ceases to grow. These stages can be seen histologically as well as radiologically. The main feature is increasing calcification of the mass. In half of our cases there was an intracranial mass with signs of raised intracranial or intra-orbital pressure. In all of these cases the mass originated from the base of skull. Those growing from the vault of the skull grew outward. Pathogenesis, diagnosis and treatment are discussed.

Hemispherectomy for the treatment of epilepsy and behavior disturbance.

This study is based on 28 personal cases. Twenty seven cases of infantile hemiplegia and one case of Stürge-Weber syndrome, with uncontrollable epilepsy and severe behaviour disturbance, were subjected to hemispherectomy. Any evidence of a defect in the other hemisphere was a contraindication to operation. In nine cases the left cerebral hemisphere was removed. Following the operation, epilepsy and behavior disturbances were abolished in nearly all of the cases. In those with left hemispherectomy there was no speech disturbance before or after the operation. It is postulated that at birth all cerebral functions including consciousness, speech, and movement are bilaterally represented, but to unequal degrees. With training and education these functions become more lateralized. Thus, we can explain the greater plasticity of the brain in childhood.

Intracranial sewing needles: Review of 13 cases.

Three new cases of intracranial sewing needles are reported and are reviewed with 10 other published cases. These needles must have been introduced in infancy before the closure of fontanelles. The intention, at least in most cases, has been infanticide. Except in one case which the mother reported and two cases found at necropsy, the others were diagnosed by skull radiography. Headache and epilepsy were the main symptoms and they often appeared when the patient had reached adulthood. Removal of the needles lessened the symptoms.

Computerized tomography in hydatid cyst of the brain.

From among 1500 patients who underwent computerized tomography (CT) during an 18-month period, five cases of hydatid disease of the brain were diagnosed. The preoperative diagnosis is of paramount importance as the cyst has to be removed unruptured. The CT features of this condition are practically pathognomonic. The authors discuss the CT findings in these cases and differential diagnosis with other cystic lesions of the brain. The help that this safe and sure method of investigation gives to attain preoperative diagnosis is emphasized.