Autopsy Practice in Ghana - Reflections of a Pathologist.

Autopsy practice in Ghana can be said to be far from satisfactory. Most Ghanaians do not know that there are different categories of death, which categories of death require an autopsy and who is required to perform the autopsy. The problems have further been complicated by the fact that, unlike other countries where separate facilities are available for storage of the different categories of dead bodies, all dead bodies in Ghana are conveyed to the hospital mortuary, thus encouraging hospitals to expand body storage facilities in their mortuaries to meet the increasing demand. Public or community mortuaries used elsewhere for storage of bodies of deaths occurring in the community pending the Coroner's directions are non-existent in Ghana. Storage of all categories of dead bodies in hospital mortuaries has resulted in virtually all autopsies being done by the hospital pathologists, especially in the large centres, at the expense of other very important diagnostic functions of the pathologist. This paper explains relevant portions of the Coroner's Act of 1960 and emphasises the need to separate the few hospital autopsies that require the expertise of the pathologist from Coroner's autopsies that may be carried out by any registered medical officer, as specified in the Act, or better still, by specially trained Forensic Physicians/Medical Examiners, as pertains in other countries. The paper also clarifies the different categories of death, those that fall in the jurisdiction of the Coroner and the personnel required to assist the Coroner in his investigastions. Suggestions have also been made on how to approach manpower development to ensure that appropriate personnel are trained to assist the Coroner in the investgation of medico-legal cases.

Pregnancy related causes of deaths in Ghana: a 5-year retrospective study.

OBJECTIVE: Data on maternal mortality varies by region and data source. Accurate local-level data are essential to appreciate its burden. This study uses autopsy results to assess maternal mortality causes in southern Ghana. METHODS: Autopsy log books of the Department of Pathology, Korle-Bu Teaching Hospital Mortuary were reviewed from 2004 through 2008 for pregnancy related deaths. Data were entered into a database and analyzed using SPSS statistical software (Version 19). RESULTS: Of 5,247 deaths among women aged 15-49, 12.1% (634) were pregnancy-related. Eighty one percent of pregnancy-related deaths (517) occurred in the community or within 24 hours of admission to a health facility and 18.5% (117) occurred in a health facility. Out of 634 pregnancy-related deaths, 79.5% (504) resulted from direct obstetric causes, including: haemorrhage (21.8%), abortion (20.8%), hypertensive disorders (19.4%), ectopic gestation (8.7%), uterine rupture (4.3%) and genital tract sepsis (2.5%). The remaining 20.5% (130) resulted from indirect obstetric causes, including: infections outside the genital tract, (9.2%), anemia (2.8%), sickle cell disease (2.7%), pulmonary embolism (1.9%) and disseminated intravascular coagulation (1.3%). The top five causes of maternal death were: haemorrhage (21.8%), abortion (20.7%), hypertensive disorders (19.4%), infections (9.1%) and ectopic gestation (8.7%). CONCLUSION: Ghana continues to have persistently high levels of preventable causes of maternal deaths. Community based studies, on maternal mortality are urgently needed in Ghana, since our autopsy studies indicates that 81% of deaths recorded in this study occurred in the community or within 24 hours of admission to a health facility.

THE SIGNIFICANCE OF EPIDERMAL GROWTH FACTOR RECEPTOR AND SURVIVIN EXPRESSION IN BLADDER CANCER TISSUE AND URINE CYTOLOGY OF PATIENTS WITH TRANSITIONAL CELL CARCINOMA OF THE URINARY BLADDER.

OBJECTIVE: To assess whether epidermal growth factor receptor (EGFR) and survivin immunostaining of tumour cells in urinary cytology and tissue of patients with bladder cancer has a prognostic significance. DESIGN: Prospective study SETTING: Department of Surgery (Division of Urology), Mubarak Al-Kabeer Teaching Hospital and Faculty of Medicine, Kuwait University, Kuwait SUBJECTS: Urine cytology smears obtainedpriorto cystoscopy in patients with transitional cell carcinoma (TCC) of the bladder were immunostained for EGFR and survivin. Bladder cancer tissue resected at surgery was also immunostained for EGFR and survivin expression. Tissue expression of EGFR and survivin in TCC of the bladder was compared to their expression in urine cytology and relationship to tumour grade and stage. RESULTS: 178 patients were studied (43 newly diagnosed bladder cancer, 58 with recurrent TCC and 77 in disease remission). Twenty five patients with normal urothelium served as controls. The mean sensitivity of urine cytology, tissue survivin immunohistochemistry (IHC) and tissue EGFR IHC was 30.5%, 62% and 59% respectively. The corresponding mean specificity was 95%, 79% and 38% respectively. For grades 1, 2 and 3 bladder tumors, tissue expression positivity for EGFR was 47.8%, 92.9%, 100% and for tissue survivin it was 27.8%, 18.2% and 33.3% respectively. For grades 1, 2 and 3 bladder tumors, urine expression positivity for EGFR was 35.7%, 40% and 67.7% and for urine survivin it was 8.3%, 42.9% and 33.3% respectively. CONCLUSION: Positive EGFR immunostaining of urine cytology specimen or tumour tissue increases with histological grade of TCC of the bladder. Survivin expression is less consistent in both urine cytology specimen and tissue samples. EGFR immunostaining may provide a useful tool in the grading of bladder TCC and aid in the selection of patients that may benefit from administration of EGFR inhibitors.

Granulomatous inflammatory response in a case of typhoid fever.

OBJECTIVE: To present a case of culture-proven typhoid fever in which granulomas were demonstrated histologically in the ileum and mesenteric lymph nodes. CLINICAL PRESENTATION AND INTERVENTION: A 47-year-old Pakistani man underwent emergency hemicolectomy for severe bleeding per rectum associated with diarrhea. Two large ulcers in the ileum, near the ileocolic junction, as well as mesenteric lymph nodes showed both necrotizing and non-necrotizing granulomas in addition to mixed inflammatory infiltrate on histology. CONCLUSION: Typhoid fever may be considered as one of the causes of the differential diagnoses of granulomatous inflammation of the small intestine.

Could nuclear matrix protein 22 (NMP22) play a role with urine cytology in screening for bladder cancer?--experience at Kuwait University.

OBJECTIVES: This prospective study was undertaken to evaluate nuclear matrix protein (NMP22) compared to urine cytology in the detection of bladder cancer and also to determine whether indexing suspicious cytology to NMP22 could enhance the clinical utility of cytology. METHODS: Cytological findings of voided urine collected prior to a cystoscopic biopsy were correlated with urine NMP22 assay in 46 patients attending the urology clinic in Mubarak Al-Kabeer Hospital. The patients were clinically categorized into newly diagnosed cases of transitional cell carcinoma (TCC), recurrent TCC, TCC in remission and controls. RESULTS: Using histological diagnosis as the gold standard the sensitivity and specificity of NMP22 were 78% and 43% respectively and of cases with malignant urine cytology were 30% and 87% respectively. If suspicious and malignant cytology were combined as positive results the sensitivity increased significantly to 87% while the specificity decreased but not significantly to 74%. Suspicious or malignant cytology enhanced by positive NMP22 gave a sensitivity of 70% and specificity of 87% neither of which was significantly different from cytology alone. There were three false positive cases on cytology and 13 false positive cases on NMP22 assay. There were three false negative cytology and five false negative NMP22 cases but only one was false negative for both, resulting in a high sensitivity (96%) but low specificity (30%) if either positive NMP22 or malignant or suspicious cytology was taken as a positive result. CONCLUSION: Combining NMP22 with malignant or suspicious cytological result improved sensitivity for the detection of bladder cancer but with a major decrease in specificity, suggesting a potential role in screening rather than diagnosis.

Indications of the mechanisms involved in improved sperm parameters by zinc therapy.

OBJECTIVE: To determine possible indications of the mechanisms involved in improved sperm parameters by zinc therapy in asthenozoospermic men. SUBJECTS AND METHODS: Forty-five men with asthenozoospermia (>or=40% immotile sperm) were randomized into four therapy groups: zinc only: n = 11; zinc + vitamin E: n = 12 and zinc + vitamins E + C: n = 14 for 3 months, and non-therapy control group: n = 8. Semen analysis was done according to WHO guidelines. Malone dialdehyde, tumour necrosis factor-alpha (TNF-alpha), total antioxidant capacity, superoxide dismutase (SOD) and glutathione peroxidase were determined in the semen and serum. Antisperm antibodies IgG, IgM and IgA were evaluated by immunobeads. Sperm chromatin integrity was determined by acid denaturation by acridine orange and sperm apoptosis by light and electron microscopy. The effect of zinc on in vitro induced sperm oxidative stress by NADH was evaluated. RESULTS: Asthenozoospermia was significantly associated with oxidative stress with higher seminal malone dialdehyde (8.8 vs. 1.8 mmol/l, p < 0.001) and TNF-alpha (60 vs. 12 pg/l, p < 0.001), and low total antioxidant capacity (1.8 vs. 8.4, p < 0.01), SOD (0.8 vs. 3.1, p < 0.01) and glutathione peroxidase (1.6 vs. 4.2, p < 0.05), compared to normozoospermia. Zinc therapy alone, in combination with vitamin E or with vitamin E + C were associated with comparably improved sperm parameters with less oxidative stress, sperm apoptosis and sperm DNA fragmentation index (DFI). On the whole, there was no difference in the outcome measures between zinc only and zinc with vitamin E and combination of vitamins E + C. In the in vitro experiment zinc supplementation resulted in significantly lower DFI (14-29%, p < 0.05) compared to zinc deficiency. CONCLUSION: Zinc therapy reduces asthenozoospermia through several mechanisms such as prevention of oxidative stress, apoptosis and sperm DNA fragmentation.

Cytomorphology of hyaline-vascular Castleman's disease: a diagnostic challenge.

OBJECTIVE: Hyaline-vascular Castleman's disease (CD) is difficult to diagnose on fine needle aspiration and may be mistaken to be a lymphoreticular malignancy because of the presence of large cells having nuclei showing atypical features. The cytomorphological findings in three histopathologically documented cases of hyaline-vascular CD were evaluated to a set of cytomorphological criteria which could help in the identification of this condition on aspirate smears. METHODS: The Papanicolaou and Diff-Quik stained smears from three cases of histologically documented hyaline-vascular CD were reviewed by one author. After review the following cytomorphological criteria were suggested to be indicators of the lesion. (i) The presence of large oval to round cells having ill-defined cytoplasmic margins and large nuclei with irregular nuclear outlines having fine or coarse chromatin giving a crumpled tissue paper appearance. (ii) A polymorphous population of lymphoid cells predominantly of small lymphocytes in the background. The smears from these three cases were then mixed with smears from four cases of reactive lymphoid hyperplasia and three cases of Hodgkin's lymphoma. These ten cases were blindly evaluated by two other cytopathologists in order to evaluate the utility of the proposed criteria in identifying CD. RESULTS: The cytomorphological criteria seen in the methodology section were present in all the cases. These features were helpful in distinguishing CD from reactive lymphoid hyperplasias and Hodgkin's Lymphomas in all cases except one case. CONCLUSION: Although hyaline-vascular CD is a difficult diagnostic entity on aspirate material the presence of large histiocytic cells with a crumpled tissue paper appearance of the nuclei in a background of small lymphocytes are useful indicators for suspecting this lesion. However, these findings should be analysed in larger studies to determine if they could in anyway reduce the diagnostic dilemma in cases of CD.

Mitochondrial ophthalmoplegia with fatigable weakness and elevated acetylcholine receptor antibody.

A 25-year-old man with chronically progressive ptosis and bilateral ophthalmoplegia displayed fatigability and fluctuation of ptosis, an abnormal single-fiber electromyogram, and a markedly elevated acetylcholine receptor antibody level. Yet a muscle biopsy showed clear evidence of a mitochondrial cytopathy, and the clinical features did not improve after treatment with prednisone. This case emphasizes the difficulty in differentiating mitochondrial cytopathy from myasthenia gravis and points out that elevated acetylcholine receptor antibody levels may occur in nonmyasthenic conditions.

Serum prostate-specific antigen levels in Middle Eastern men with subclinical prostatitis.

OBJECTIVE: To investigate the influence of subclinical or histologically diagnosed prostatitis on serum prostate-specific antigen (PSA) in patients investigated for prostatic disease in Kuwait. MATERIALS AND METHODS: Serum PSA was assayed in patients investigated for prostatic disease in Mubarak Al-Kabeer Hospital, Kuwait, between December 2002 and December 2004. These included patients undergoing transrectal ultrasound with needle biopsy of the prostate gland and those who were treated with transurethral resection of the prostate or retropubic prostatectomy. The tissue was evaluated for prostatitis as well as the underlying disease, and the type and severity of prostatitis were compared with levels of serum PSA. RESULTS: Of the 331 tissue specimens, 18 (5.4%) did not show prostatitis, while 233 (70.4%) with benign prostate and 80 (24.2%) with malignant prostate disease showed prostatitis. Of 270 men with known serum PSA levels, 198 and 72 had benign and malignant prostate disease, respectively. Of the 198, 77 (41%) with benign prostate disease and prostatitis and of the 72, 52 (76%) with malignant prostate disease and prostatitis had serum PSA levels >10 ng/ml. CONCLUSION: The data showed that although raised serum PSA is more commonly associated with prostate cancer, subclinical prostatitis is a significant source of high serum PSA in over 40% of men in Kuwait. That local factors may obscure the usefulness of serum PSA as a screening tool suggests the need for a locally applicable paradigm to identify prostate cancer.

Relationship between serum prostate specific antigen and the pattern of inflammation in both benign and malignant prostatic disease in Middle Eastern men.

To determine the effect of prostatitis on serum prostate specific antigen in the diagnosis of prostate cancer in Middle Eastern men, H&E-stained sections of all consecutive prostate specimens were reviewed for diagnosis (malignant or benign) and pattern of inflammation. Inflammation was categorized into acute, active chronic and chronic inactive and graded semi-quantitatively according to previously published criteria. Results were correlated with serum PSA obtained from patients' records. Of 513 prostate specimens reviewed; 435 (84.8%) were benign and 78 (15.2%) were malignant. Chronic inactive prostatitis was present in 259 (204 benign, 55 malignant) and active chronic prostatitis in 221 (204 benign, 17 malignant). Acute prostatitis alone was not observed and prostatitis was absent in 33 (27 benign, 6 malignant). There was no significant difference in the prevalence of inactive chronic prostatitis between benign and malignant specimens (p < 0.071), but active chronic prostatitis was more prevalent in benign specimens (p < 0.001). Increasing serum PSA was observed for increasing grades of both inactive and active chronic prostatitis in both benign and malignant disease. Prostate cancer showed higher serum PSA levels than benign, at different cut-off points (4 ng/ml = p < 0.0001; 8 ng/ml = p < 0.0001; 12 ng/ml = p < 0.0001). However, significant numbers of patients with benign prostate biopsies presented with PSA above 12 ng/ml (82/260 = 32%). We conclude that active chronic prostatitis is common in Middle Eastern men with benign prostatic disease and a significant number of these present with very high PSA levels, some over 300 ng/ml.

Angiotensin-(1-7) prevents development of severe hypertension and end-organ damage in spontaneously hypertensive rats treated with L-NAME.

We examined the influence of chronic treatment with ANG-(1-7) on development of hypertension and end-organ damage in spontaneously hypertensive rats (SHR) chronically treated with the nitric oxide synthesis inhibitor L-NAME (SHR-L-NAME). L-NAME administered orally (80 mg/l) for 4 wk significantly elevated mean arterial pressure (MAP) compared with SHR controls drinking regular water (269 +/- 10 vs. 196 +/- 6 mmHg). ANG-(1-7) (24 microg x kg(-1) x h(-1)) or captopril (300 mg/l) significantly attenuated the elevation in MAP due to L-NAME (213 +/- 7 and 228 +/- 8 mmHg, respectively), and ANG-(1-7) + captopril completely reversed the L-NAME-dependent increase in MAP (193 +/- 5 mmHg). L-NAME-induced increases in urinary protein were significantly lower in ANG-(1-7)-treated animals (226 +/- 6 vs. 145 +/- 12 mg/day). Captopril was more effective (96 +/- 12 mg/day), and there was no additional effect of captopril + ANG-(1-7) (87 +/- 5 mg/day). The abnormal vascular responsiveness to endothelin-1, carbachol, and sodium nitroprusside in perfused mesenteric vascular bed of SHR-L-NAME was improved by ANG-(1-7) or captopril, with no additive effect of ANG-(1-7) + captopril. In isolated perfused hearts, recovery of left ventricular function from 40 min of global ischemia was significantly better in ANG-(1-7)- or captopril-treated SHR-L-NAME, with additive effects of combined treatment. The beneficial effects of ANG-(1-7) on MAP and cardiac function were inhibited when indomethacin was administered with ANG-(1-7), but indomethacin did not reverse the protective effects on proteinuria or vascular reactivity. The protective effects of the ANG-(1-7) analog AVE-0991 were qualitatively comparable to those of ANG-(1-7) but were not improved over those of captopril alone. Thus, during reduced nitric oxide availability, ANG-(1-7) attenuates development of severe hypertension and end-organ damage; prostaglandins participate in the MAP-lowering and cardioprotective effects of ANG-(1-7); and additive effects of captopril + ANG-(1-7) on MAP, but not proteinuria or endothelial function, suggest common, as well as different, mechanisms of action for the two treatments. Together, the results provide further evidence of a role for ANG-(1-7) in protective effects of angiotensin-converting enzyme inhibition and suggest dissociation of factors influencing MAP and those influencing end-organ damage.

Utility of volume adjusted prostate specific antigen density in the diagnosis of prostate cancer in Arab men.

BACKGROUND: This study was undertaken to assess the utility of prostate specific antigen (PSA) and PSA density (PSAD) in discriminating between benign and malignant prostate disease in the Kuwaiti Arab population. METHODS: A total of 100 consecutive patients suspected of having prostate cancer because of serum PSA > 4 ng/ml, or detection of a prostatic nodule on rectal examination were further investigated by determination of PSAD, TRUS of prostate, sexant prostatic biopsy and histological analysis to establish the correct diagnosis. Other diagnostic measures included the determination of the area under the receiver operating characteristic (ROC) curve, sensitivity and specificity. RESULTS: Of the 100 prostate biopsies that were performed, 33 cases were confirmed to be prostate cancer and 67 were described as benign lesions comprising benign prostatic hyperplasia (BPH) with or without prostatitis. The age range for patients with prostate cancer was 42-90 years, and 52-90 years for those without prostate cancer. The mean prostate volume was 58.82 cc (range 9-177 cc) and 62.60 cc (range 15-140 cc), the mean PSA value was 36.65 ng/ml (range 5.8-200 ng/ml) and 16.49 ng/ml (range 1.4-46.0 ng/ml), while the mean PSAD was 0.92 (range 0.046-5.714) and 0.452 (range 0.034-2.294) for patients with prostate cancer and patients without prostate cancer respectively. Patients with PSA less than 4 ng/ml (3 cases) all had benign prostate lesions, and 7 cases with PSA more than 50 ng/ml all had prostate cancer and were excluded because values above 50 ng/ml have close to 100% specificity for prostate cancer. Further analysis was done on the remaining 90 cases which were patients with a PSA between 4 and 50 ng/ml. The discriminating power of serum PSA for detecting prostate cancer as estimated by the area under ROC was 0.686 while that for PSAD was 0.732. The maximum likelihood for a positive PSA was at a PSAD cut-off point of 0.32. For the PSA cut-off point of l0 ng/ml, the sensitivity was 80%, and specificity was 42.2%. For the PSAD cut-off point of 0.32, the sensitivity was 58% and the specificity 76.6%. CONCLUSIONS: Determination of PSAD is not a useful adjunct to serum PSA values in the range of 10-50 ng/ ml in our population. PSAD value less than 0.32 with PSA less than l0 ng/ml strongly suggests benign disease.

Morphological responses of the rabbit testis to ischemic/reperfusion injury due to torsion.

OBJECTIVE: To investigate the morphological effects of free radical injury on spermatogenic cells in both testes of the rabbit experimental model of testicular torsion. MATERIALS AND METHODS: The left testes of 8 peripubertal NZW rabbits (3-6 months) were subjected to 0, 15, 30, 60, 90, 120, and 180 min of ischemia by applying a clamp to the spermatic cord, followed by reperfusion. Another set of 8 rabbits was subjected to 60 min of ischemia and administered antioxidants (acetylsalicylic acid, ascorbic acid, allopurinol, quercetin, superoxide dismutase) before reperfusion. Both testes of 4 animals per group were harvested at 24 h and the remaining 4 at 3 months. Johnsen scores for spermatogenic activity and other changes were assessed histologically and these were compared with testicular malondialdehyde (MDA), a measure of free radical damage, assayed on testicular homogenates using the thiobarbiturate method. RESULTS: In the 24-hour reperfusion group, apoptotic bodies and giant cells were more prominent in the seminiferous tubules of the left testes compared to the right, and were maximal after 90 min. In the 3-month reperfusion group, giant cells were absent, and apoptotic bodies were reduced in both testes. Testicular MDA showed an increase only in the left testes in the 24-hour reperfusion group, while the 3-month group showed increased MDA levels in both testes, but more on the left. The Johnsen score fell only to 8.0 in the left testes in the 24-hour reperfusion group, but dropped to 2.3 in the 3-month reperfusion group. Only in the 3-month reperfusion group, did antioxidant-treated animals show a fall in Johnsen scores in the left testes, regardless of the type of antioxidant. CONCLUSION: These findings confirm a role for reactive oxygen species (ROS) in damage to spermatogenic cells in both the ipsilateral and contralateral testes following torsion, with longer term effects in the torted testis. Currently available antioxidants do not provide any significant long-term protection against morphological damage to the testis by ROS generated in testicular torsion.

BRCA1 gene expression in breast cancer in Kuwait: correlation with prognostic parameters.

OBJECTIVES: This study assessed the BRCA1 gene expression in breast cancer in Kuwait, and compared it with other known prognostic factors for the disease. MATERIALS AND METHODS: Forty-eight random samples of archival paraffin-embedded breast cancer tissues were studied for BRCA1 gene expression. Immunohistochemical method utilizing antibodies against different epitopes on the BRCA1 protein was used to study BRCA1 protein expression. In addition, for 29 patients, reverse transcription-polymerase chain reaction was used to detect BRCA1 mRNA expression. BRCA1 expression was correlated with age, histological type and grade of breast cancer, estrogen and progesterone receptor status, and C-erbB-2 expression. RESULTS: No demonstrable BRCA1 mRNA and protein expression was found in 79 and 83% of the breast cancer tissues, respectively. A positive relationship was demonstrated between lack of BRCA1 (mRNA and protein) expression and high histological grade, negative estrogen and progesterone receptor status, and overexpression of C-erbB-2 in the breast cancer tissues. CONCLUSIONS: The study demonstrated lack of BRCA1 gene expression (mRNA and protein) in the majority of breast cancers in Kuwait and confirmed the inverse relationship between BRCA1 expression and parameters that determine poor prognosis in breast cancer.

Pleomorphic adenoma of salivary gland: to what extent does fine needle aspiration cytology reflect histopathological features?

OBJECTIVE: The histological diversity encountered in pleomorphic adenoma may cause diagnostic difficulty in fine needle aspiration (FNA) cytology due to limited and selective sampling. The present study based on 25 histologically confirmed pleomorphic adenoma cases attempts to find out to what extent FNA cytology reflects the histopathological features. METHODS: May-Grunwald-Giemsa and Papanicolaou stained smears, and haematoxylin and eosin stained paraffin sections of 25 pleomorphic adenomas of parotid and submandibular glands were reviewed. The cellularity, which was assessed in a sliding scale of 1+ to 4+, and proportions of epithelial to mesenchymal components in FNA smears and histology was determined and compared. The frequency of morphological features such as squamous metaplastic cells, cells with oncocytic change, acinus formation, mucus globules, papilla formation, giant cells, myxoid and chondroid matrix as well as specific nuclear features was compared between the two diagnostic methods, and the statistical significance was determined using Fisher's exact test of probability. RESULTS: There was complete concordance between cytology and histology with respect to overall cellularity in 14 (56.0%) cases and in the proportions of epithelial to mesenchymal components in 13 (52.0%). Epithelial cells and myxoid matrix were present in all cases. There was no significant difference between smear and tissue section with respect to frequency of squamous metaplasia, oncocytic change, acinus formation, papilla formation, mucus globules, giant cells, nuclear pleomorphism, nuclear chromatin pattern, and mitotic figures. Morphological parameters that were significantly higher in FNAC compared with histology included intranuclear cytoplasmic inclusions (36.0% versus 8.0%, p = 0.0374), nuclear grooves (84.0% versus 48.0%, p = 0.0090), and reniform nuclei (20.0% versus 0.0%, p = 0.0502). Chondroid matrix was the only parameter which was significantly more common in histology than in cytology (44.0% versus 4.0%, p = 0.019). CONCLUSION: FNA cytology demonstrates well most of the histological features of pleomorphic adenoma of salivary gland and may be considered a useful tool in initial assessment of the tumour.

Giant cell arteritis of the breast.

OBJECTIVE: To report a rare case of giant cell arteritis of the breast in a 56-year-old woman. CLINICAL PRESENTATION AND INTERVENTION: The patient presented with tenderness in the upper outer quadrant of the left breast, in the absence of any constitutional symptoms. A diagnosis of giant cell arteritis was made only after surgical wedge excision of the affected breast quadrant. She returned 6 weeks later with tenderness in the upper inner medial quadrant of the same breast, with a raised erythrocyte sedimentation rate. She has since been referred to the rheumatologist for further management. CONCLUSION: The diagnosis of giant cell arteritis of the breast was made only after pathological examination of the excised breast tissue. This study focused attention on the need to be aware of systemic conditions that may present as localised lesions of the breast and to maintain a high index of clinical suspicion in order to adequately investigate them and perhaps avoid unnecessary radical surgical intervention such as mastectomy.

High serum prostate-specific antigen levels in the absence of prostate cancer in Middle-Eastern men: the clinician's dilemma.

OBJECTIVE: To investigate the common causes of total serum prostate-specific antigen (PSA) values of> 10 ng/mL in an Arab population, as in the USA and Europe the risk of prostate cancer is considered high in men with such PSA levels. PATIENTS AND METHODS: Serum total PSA was measured in men presenting to our hospital as part of the investigation for prostate cancer screening and/or in elderly men with prostatism. Men with a serum PSA level of> 10 ng/mL were further investigated by transrectal ultrasonography (TRUS) of the prostate and biopsy of suspicious lesions for histological diagnosis. In addition, the percentage of free PSA, PSA velocity and PSA density were determined. All the patients included in this study were men of Arab origin residing in Kuwait. RESULTS: In all, 1700 men (mean age 55.6 years, range 35-94) were assessed; of these, 161 had a serum PSA of> 10 ng/mL, attributable to benign prostatic hyperplasia (BPH) in 110 (68%), BPH with histological features of prostatitis in 33 (21%) and prostate cancer in 18 (11%). TRUS of the prostate in 143 of the 161 men with either BPH or BPH with prostatitis showed varying grades of intraprostatic calcifications in 22 (15%). Both PSA density and percentage free PSA did not contribute to determining the causes of total PSA levels of> 10 ng/mL. There was a progressive decline in PSA in all patients with BPH and prostatitis, except one who at re-biopsy had prostate cancer (T1N0M0, G1). CONCLUSION: Total PSA values of> 10 ng/mL in Arab men may be a result of BPH, BPH with prostatitis or prostate cancer, in that order. A gradual decline in total PSA (decreased PSA velocity) with time to < 4 ng/mL often confirms the diagnosis of BPH with prostatitis. The percentage of free PSA and PSA density may not be helpful in diagnosing prostate cancer with certainty in these patients. Compared with Caucasians in the USA and Europe, BPH and BPH with prostatitis appear to be more frequent causes of serum PSA levels of> 10 ng/mL in Arab men.

Effect of castration on acetyl salicylic acid metabolism in rabbits.

OBJECTIVES: The biotransformation of acetyl salicylic acid (ASA) differs within species, and gender differences have been documented and attributed to the effect of sex hormones. Castration remains a standard therapy for men with advanced prostate cancer. We studied the effect of castration on the metabolism of ASA in rabbits to find out whether the metabolism of ASA is adversely affected after castration. METHODS: ASA in doses of 12.5, 25, and 50 mg/kg body weight was given intravenously to male and female prepubertal and adult rabbits, castrated adult male rabbits, and castrated male rabbits given testosterone (3 animals per group). Blood samples were collected at 0, 10, 30, 60, 120, and 180 minutes. The high-performance liquid chromatography method was used for the quantitation of salicylic acid (SA) in serum. The percentage of SA not metabolized was determined by comparing the serum level at 10 and 180 minutes for each group. RESULTS: At a dose of 50 mg/kg in the adult rabbits, the mean +/- SD of SA in serum at 10 and 180 minutes was 146.54 +/- 29.54 microg/mL and 19.12 +/- 5.93 microg/mL for males, 158.25 +/- 6.70 microg/mL and 33.24 +/- 2.78 microg/mL for females, 229.72 +/- 47.85 microg/mL and 44.33 +/- 5.64 microg/mL for castrated male rabbits, and 170.88 +/- 12.03 microg/mL and 68.1 +/- 37.54 microg/mL for castrated male rabbits given testosterone, respectively. Also, at 180 minutes, the percentage of SA not metabolized in adult male rabbits was 12.82% +/- 1.65% compared with 21.04% +/- 2.14% (P <0.01) in adult females, 19.53% +/- 1.73% (P <0.01) in castrated adult male rabbits, and 38.95% +/- 19.48% (P <0.001) in castrated male rabbits given testosterone. At all doses of ASA, the serum SA concentration in male and female prepubertal rabbits was not significantly different for each time point. CONCLUSIONS: These results indicate that male rabbits are able to metabolize ASA faster than are females. After castration, this ability is significantly decreased. If these experimental results are confirmed in humans, men who are undergoing hormonal manipulation for advanced prostate cancer and who require high-dose ASA, such as in the treatment of stroke or rheumatoid arthritis or as an antioxidant, may need lower doses to reduce the possible toxic effects of ASA.

Leiomyosarcoma complicating chronic inflammation of the testis.

OBJECTIVE: To report on a case of leiomyosarcoma of the testis that appeared to have arisen from a background of chronic testicular inflammation. CLINICAL PRESENTATION: A 65-year-old man with a 15-year history of diabetes mellitus and low-grade discomfort and swelling in the right testis presented as an emergency with exacerbation of the pain and swelling of the testis. Repeated ultrasound examination of the testis in the past 5 years had suggested a chronic testicular inflammatory disorder. Ultrasound during the current emergency case admission revealed a normal left testis, but a large heterogeneous solid mass with a moderate intratesticular calcification in the right testis and the presence of a moderate hydrocele. Serum alpha-fetoprotein and beta-human chorionic gonadotropin were normal. A right radical orchidectomy was performed. Histopathology and immunohistochemistry revealed primary leiomyosarcoma of the right testis. There was no spermatic cord or venous involvement. One year after orchidectomy there was no sign of metastasis. CONCLUSION: Radical orchidectomy followed by surveillance appears to be the treatment of choice for this testicular leiomyosarcoma, which seemed to have run an indolent course compared to other testicular tumours.