Surgical re-excision vs. observation for histologically dysplastic naevi: a systematic review of associated clinical outcomes.

BACKGROUND: The management of histologically dysplastic naevi (HDN) with re-excision vs. observation remains controversial because of lack of evidence about associated melanoma outcomes. OBJECTIVES: To assess published data on the development of biopsy-site primary cutaneous melanoma among biopsy-proven HDN managed with either re-excision or observation. METHODS: A systematic review of all published data: a total of 5293 records were screened, 18 articles were assessed in full text and 12 studies met inclusion criteria. No controlled trials were identified. RESULTS: Most studies (11 of 12, 92%) were retrospective chart reviews, and one was both a cross-sectional and cohort study. Many studies (nine of 12, 75%) had no head-to-head comparison groups and either only reported HDN that were re-excised or observed. A total of 2673 (1535 observed vs. 1138 re-excised) HDN of various grades were included. Follow-up varied between 2 weeks and 30 years. Nine studies reported that no melanomas developed. Eleven biopsy-site melanomas developed across three of the studies, six among observed lesions (0·39%) and five among re-excised lesions (0·44%). CONCLUSIONS: Based upon the available evidence the rates of biopsy-site primary melanoma were similarly low among observed lesions and re-excised lesions. This suggests that HDNs can be observed with minimal adverse melanoma-associated outcomes. However, all included articles were of low quality and further prospective trials could better guide clinical decision making.

Procoagulant properties of benign and malignant prostatic tissue.

OBJECTIVE: To determine the factor-X activating procoagulant activity (FXAA) of prostatic tissue removed at transurethral resection in a specific chromogenic assay. PATIENTS AND METHODS: FXAA was extracted from transurethrally resected prostatic tissue using a cryofragmentation technique. Tissue from 50 patients with prostate cancer was analysed and compared with that from 36 control patients with benign prostatic-hypertrophy. Enzyme activities were assayed in a two stage chromogenic assay and correlated with conventional markers of tumour aggressiveness. RESULTS: FXAA was found to be significantly lower (P < 0.001) in tissue from malignant prostates compared with benign prostatic hypertrophy tissue. Loss of FXAA was also related to Gleason grade (P < 0.03), percentage of chips involved by tumour (P < 0.04) and bone scan status (P < 0.02). Using antibody inhibition tests this procoagulant was characterized as being a factor VII/tissue factor complex. CONCLUSIONS: Malignant change in the prostate is associated with a reduction in FXAA and this may be an important factor in prostatic tumour growth and dissemination.

Procoagulant activity may be a marker of the malignant phenotype in experimental prostate cancer.

Using a one-stage kinetic chromogenic assay, we studied the procoagulant activity (PCA) of prostatic tissue in an experimental model of prostate cancer in the rat. PCA was present in homogenates of rat prostate glands containing either benign or malignant tumours. The procoagulant activated factor X directly and was provisionally characterised as a tissue factor-factor VIIa complex. There was no significant differences in PCA between control rats and rats exposed to carcinogens that did not develop tumour. Levels in rats that developed tumours were significantly higher (P < 0.01) than all other groups and there was a positive correlation between tumour weight and PCA (r = 0.85, P < 0.001). Furthermore, prostatic PCA levels were higher in the metastasis (P < 0.02). We conclude that PCA reflects the malignant phenotype in this animals, the PCA of the primary tumour was compared with that of the corresponding secondary deposit and levels were higher in the metastasis (P < 0.02). We conclude that PCA reflects the malignant phenotype in this model of experimental prostate cancer and suggest that this parameter is worth evaluating as a potential tumour marker in the human disease.

Urinary tissue factor levels in prostatic carcinoma: a potential marker of metastatic spread?

Recent investigations have suggested that levels of urinary tissue factor (UTF) may be elevated in some forms of cancer. We have determined UTF levels in healthy controls, patients presenting for surgery with benign prostatic hypertrophy (BPH) and untreated prostate cancer. Patients undergoing check cystoscopy, who were free of recurrent bladder cancer, and a cohort of men with bone scan positive prostate cancer recently treated by androgen ablation were also studied. UTF levels were higher in patients with prostate cancer when compared with controls, those undergoing check cystoscopy and patients with BPH. In patients with prostate cancer, bone scan positive patients had higher levels than bone scan negative subjects. The androgen ablated group had UTF levels similar to those of the control groups and significantly lower than the bone scan positive group. A weak correlation was found between UTF and serum prostate specific antigen (PSA) levels when patients with BPH and untreated cancer were analysed, but no correlation was demonstrable between PSA and UTF when cancer patients alone were evaluated. It was concluded that UTF levels are elevated in untreated prostate cancer and reflect bone scan status. In patients with bone scan positive disease UTF also reflects disease activity and may therefore be a useful disease marker in prostate cancer.

Tethered cord syndrome: an unusual cause of adult bladder dysfunction.

Tethered cord syndrome is a complication of spinal dysraphism. The tethering of the cord does not permit the normal cranial migration of the conus within the vertebral canal and this results in neural dysfunction due to a traction neuropathy. Although this condition commonly presents in childhood, less severe degrees of tethering may remain asymptomatic until adult life. The clinical features, imaging and management of 5 adults with this condition are reviewed. Both urological and neurosurgical intervention are aimed at preservation of function as, unlike the sensorimotor deficit that commonly complicates this condition, improvement in bladder function is uncommon following cord release.

Coagulopathy in the prostate cancer patient: prevalence and clinical relevance.

Carcinoma of the prostate has historically been associated with the bleeding diathesis which accompanies disseminated intravascular coagulation. We have performed a prospective study into the prevalence of coagulopathy in patients with untreated prostate cancer using matched patients with benign prostatic hypertrophy (BPH) as controls. Haemostatic activation was assessed by measuring fibrinopeptide A (FpA) by an ELISA and D-dimer by a latex agglutination assay. FpA and D-dimer levels were correlated with serum prostate specific antigen (PSA) and bone scan status. Of the cancer patients, 40% had elevated FpA, levels being higher in those with bone scan positive disease (P < 0.05). D-dimer was detectable in 24% of those with prostate cancer but in none with BPH. Neither FpA nor D-dimer were related to serum PSA but D-dimer appeared to be a predictor of bone scan status with a positive predictive value of 91%. It is concluded that changes compatible with subclinical DIC are common in patients presenting with prostate cancer and that measurement of FpA and D-dimer may have roles as tumour markers in this disease.

Total nephrectomy in children: a clinicopathological review.

The records of 85 children undergoing total nephrectomy have been reviewed. Diagnoses ranged between pyelonephritis (37 patients), renal tumours (25), renal dysplasia and multicystic kidney (16), obstructive uropathy (6) and renal vein thrombosis (1). In the pyelonephritic group a contributory ipsilateral abnormality was demonstrated in 36 of the 37 children. Vesicoureteric reflux (VUR) was the most common abnormality in this cohort and was usually of a severe grade. Calculus disease was present in 9 patients, only 1 of whom had VUR. Of the remaining 7 patients with pyelonephritis, 6 had evidence of obstruction to the upper tracts. Calculus disease poses a more severe threat to the childhood kidney than the well known risk factors of vesicoureteric reflux and obstructive uropathy.

Urinary tissue factor levels in transitional cell carcinoma of the bladder.

Production of procoagulant activity by host and tumour cells may be increased in patients with cancer. Using a simple chromogenic assay, we have determined urinary tissue factor (TF) levels in patients presenting with transitional cell carcinoma of the bladder (TCC, n = 63), normal controls (n = 20) and patients with benign prostatic hypertrophy (BPH, n = 35). In addition, a separate cohort of patients undergoing endoscopic surveillance for superficial bladder cancer were studied to determine whether there was any difference in levels in those with recurrent disease compared to those with normal cystoscopies. Urinary TF activity was higher in TCC compared to controls (p less than 0.001) and patients with BPH (p less than 0.05). In patients undergoing check cystoscopy, those with recurrent disease (n = 32) had higher levels (p less than 0.01) than those with normal examinations (n = 21). It is concluded that urinary TF levels are elevated in bladder cancer and that this reflects disease activity in those at risk of recurrent superficial disease.

Endoscopic placement of CAPD catheters: a review of one hundred procedures.

One hundred consecutive endoscopically placed peritoneal dialysis catheters inserted in 95 patients over an 18-month period have been reviewed. All catheters were placed for chronic dialysis (CAPD). Following insertion there were five early catheter failures (4 failed to drain, 1 perforated viscus) and 13 early complications (7 leaks, 3 tunnel bleeds, 2 scrotal oedema, 1 wound infection). In the long term six patients required transfer to haemodialysis (2 recurrent peritonitis, 2 pain on outflow, 1 unable to cope, 1 persistent vomiting). Overall probability of catheter survival as predicted by Kaplan-Meier analysis was 0.85 at 18 months. These results confirm that endoscopic placement of CAPD catheters is safe and reliable. In addition there is a low early failure rate and the long-term catheter survival figure is comparable with the best series reported. This procedure allows direct visualization of the peritoneal cavity, thus minimizing the risk of visceral damage. Furthermore, the procedure is well tolerated under local anaesthesia and allows early institution of dialysis because of the extremely low leakage rate (11%). Endoscopic placement of CAPD catheters is now the procedure of choice in our centre. General anaesthetic and mini-laparotomy are thus avoided in most of this high-risk group.

Atheroembolism presenting as selective muscle embolisation.

Two cases of occult aneurysmal disease presenting with select muscle embolisation are described. Both cases were characterised by symptomatology suggestive of occlusive disease but in the presence of normal pulses. It is concluded that the clinical features allow early diagnosis of this uncommon presentation of aneurysmal disease.

Post 131I carcinoma of the thyroid.

A case of post-radioiodine follicular carcinoma of the thyroid is presented. Current evidence suggests no causal relationship. The evidence for this assertion is reviewed with the conclusion that a note of caution is still required.