Does mpMRI improve clinical criteria in selecting men with prostate cancer for active surveillance?

BACKGROUND: Active surveillance (AS) has excellent short to medium term outcomes in well-selected prostate cancer patients. Traditional biopsy-based selection criteria have been criticized for inaccurate determination of cancer grade and extent. We evaluated the incremental benefit of multiparametric magnetic resonance imaging (mpMRI) in patient selection using various AS criteria. METHODS: We retrospectively evaluated men who received mpMRI before radical prostatectomy between 2011 and 2014. Patients were classified as suitable for AS using four criteria: (1) Epstein, (2) National Comprehensive Cancer Network (NCCN) low-risk or (3) extended criteria (Gleason ⩽3+4, PSA ⩽15 ng/ml, clinical stage ⩽T2b) using clinical parameters. The incremental value of mpMRI was evaluated against the referent standard of surgical pathology in determining suitability for AS using sensitivity, specificity, likelihood ratios (LRs) and area under receiver operating curves (AUCs). RESULTS: We evaluated 208 men. Only one man fulfilled Epstein criteria (1) at pathology, who was neither identified using clinical criteria nor mpMRI. Using (2), clinical criteria had a sensitivity of 80%, specificity 75%, LR+ 3.3, LR- 0.3, AUC 0.78, while combined clinical-mpMRI criteria achieved a sensitivity of 80%, specificity 99.5% (P<0.01), LR+ 162, LR- 0.2 and AUC 0.90 (P<0.01 compared to clinical). Using (3), clinical criteria had a sensitivity of 74%, specificity 47%, LR+ 1.4, LR- 0.6, AUC 0.60, while combined clinical-mpMRI criteria achieved a sensitivity of 26% (P<0.01), specificity 97% (P<0.01), LR+ 8.3, LR- 0.8 and AUC 0.62 (P=0.85). CONCLUSIONS: Addition of mpMRI significantly improved selection of men for AS using NCCN low-risk criteria. For selecting men with limited prognostic grade group 2, mpMRI significantly improved specificity at the expense of sensitivity.

Prenatal ultrasound evaluation of fetal diastematomyelia: two cases of type I split cord malformation.

Isolated diastematomyelia is a rare form of spinal dysraphism characterized by a sagittal cleft in the spinal cord, conus medullaris and/or filum terminale with splaying of the posterior vertebral elements. This condition is the result of the presence of an osseous or fibrocartilaginous septum producing a complete or incomplete sagittal division of the spinal cord into two hemicords. It may be isolated or associated with other segmental anomalies of the vertebral bodies. Prenatal diagnosis of this anomaly is possible in the early midtrimester by sonography, thus allowing for early surgical intervention and a favorable prognosis. Two cases of fetal diastematomyelia diagnosed by prenatal sonography are presented, each demonstrating the typical sonographic features diagnostic of this condition. The first case, detected at 28 weeks' gestation, presented with disorganization of the bony processes of the vertebral column with a midline echogenic focus. The second fetus, diagnosed at 17 weeks' gestation, had a similar appearance with widening of the posterior elements and the presence of a midline echogenic bony spur. Postnatally, both infants underwent magnetic resonance imaging for a definitive diagnosis. Surgical repair of the defect was performed in the neonatal period in both cases.

Twin pregnancy in a woman on long-term epoprostenol therapy for primary pulmonary hypertension. A case report.

BACKGROUND: Pregnancy associated with primary pulmonary hypertension is an uncommon observation, with maternal mortality > 50%. Experience treating this condition is limited. Past reports have emphasized the need for pregnancy termination. In the last few years there has been considerable interest in long-term intravenous use of epoprostenol (prostacyclin) in patients with primary pulmonary hypertension. CASE: A woman with severe primary pulmonary hypertension who was on long-term epoprostenol therapy became pregnant with twins and was treated with high doses of epoprostenol and nitric oxide during delivery and the postpartum period. She was well six months later on continuous epoprostenol therapy. The one viable infant was alive and still hospitalized at this writing. CONCLUSION: Epoprostenol therapy may be continued during pregnancy in patients with severe primary pulmonary hypertension for long-term pulmonary vasodilatation.

In utero treatment of fetal complete heart block with terbutaline. A case report.

BACKGROUND: Isolated fetal complete heart block is an uncommon finding, with a mortality rate of 20-30%. Various treatment modalities have been reported, with no consistent success. CASE: Fetal complete heart bock was diagnosed in a 30-year-old woman at 29 weeks' gestation. She had an elevated antinuclear antibody and anti-SSA antibody titer. Fetal cardiac decompensation was detected at 32 weeks. After a trial of intravenous isoproterenol without significant side effects, she was treated with oral terbutaline. An increase in the fetal ventricular rate and complete resolution of hydrops fetalis occurred. A male infant was delivered by cesarean section, at term, and underwent cardiac pacemaker implantation at 4 days of age. CONCLUSION: The treatment of fetal complete heart block is controversial. Premature delivery with cardiac pacing is associated with high morbidity and mortality. We report prenatal treatment with oral sympathomimetic medication, which allowed delivery to be delayed until term, with a successful outcome.

Prenatal identification of a completely cystic internal sacrococcygeal teratoma (type IV).

Sacrococcygeal teratomas can be diagnosed prenatally with a detailed ultrasound examination of the fetal anatomy. The majority of these teratomas are solid or mixed cystic and solid external caudal masses. A conclusion drawn from the literature is that only a small percentage are entirely cystic and few are completely internal or presacral without external component (Type IV). This report describes an unusual case of a large completely internal cystic sacrococcygeal teratoma identified prenatally by ultrasonography at 32 weeks' gestation. The differential diagnosis for this unique presentation of sacrococcygeal teratoma is different from that considered for predominantly external complex tumors.

Hyperbaric oxygen treatment during pregnancy in acute carbon monoxide poisoning. A case report.

BACKGROUND: Carbon monoxide poisoning in pregnancy is a relatively rare occurrence, with potentially serious complications for both mother and fetus. Controversy regarding treatment during pregnancy exists primarily due to the concern for oxygen toxicity in the fetus. However, rapid oxygen dissociation and prolonged clearance of carbon monoxide in the fetal circulation emphasize the importance of adhering to aggressive treatment protocols. CASE: A 22-year-old employee at an office undergoing repairs on the heating and ventilation systems presented with neurologic symptoms, tachycardia, tachypnea, signs of preterm labor and a carboxyhemoglobin level that was mildly elevated. Fetal monitoring demonstrated a reactive nonstress test with mild to moderate repetitive variable decelerations. The patient underwent hyperbaric oxygen treatment, with complete resolution of her neurologic symptoms, tachycardia and tachypnea as well as fetal variable decelerations. She was additionally treated with intravenous magnesium sulfate tocolysis, with cessation of contractions. The patient subsequently delivered at term; the viable infant had no sequelae of in utero carbon monoxide poisoning. CONCLUSION: This case supports previously published recommendations for treating acute carbon monoxide poisoning during pregnancy with hyperbaric oxygen. As more cases are gathered, a more widely accepted set of standards can be established.

Prenatal diagnosis of congenital imperforate hymen.

BACKGROUND: Congenital imperforate hymen is an external urogenital anomaly that has a small differential diagnosis. With careful antenatal sonographic evaluation of the female perineum, identification of a thin protruding membrane consistent with imperforate hymen can be made. CASE: We report a case in which an imperforate hymen was diagnosed in a fetus at 25 weeks' gestation. It appeared as a thin membrane that distended the vagina and spread the labia majora because of retained secretions. An associated renal abnormality was present, representing either a right multicystic dysplastic kidney or cystic dysplasia. CONCLUSION: Imperforate hymen and hydrocolpos can be diagnosed as early as the second trimester. Because of the additional renal anomaly in this case, it is suggested that the presence of prenatally diagnosed imperforate hymen warrants a careful survey of the remaining fetal anatomy to rule out associated abnormalities. The possibility of a familial occurrence should be considered, and the appropriate history should be obtained.