A Large Follicular Dentigerous Cyst: A New Multi-portal Access: Intraoral and Endoscopic Technique.

Background: The standard treatment for a dentigerous cyst of maxilla is a surgical enucleation, the extraction of the tooth. In the case of cysts involving the maxillary sinus, a Caldwell-Luc approach is used. In case of large cysts, its marsupialization is carried out in order to reduce the bone defect, followed by enucleation and extraction of the tooth. Methods: This is a case of a large follicular dentigerous cyst of upper jaw with 18 ectopic tooth within the maxillary sinus, treated in our Unit. Results: We decided to perform a multi-portal access, the intraoral endoscopic-assisted technique; an intraoral approach has been performed, but less demolishing than the routine intraoral approach, through the anterior wall of the maxillary sinus, already eroded by the lesion. The lesion was very large, occupying the entire maxillary cavity. For this reason, by means of the intraoral approach alone, it was extremely difficult to remove the lesion in its entirety. The endoscopic-assisted technique was combined with intraoral approach. The lesion extended to the maxillary ostium. This did not allow to reach the ostium through the classic endoscopic approach. Endonasal endoscopic access was used both to enucleate the cyst, that was adherent to the orbital floor and soft tissues of the OMC (osteomeatal complex), and to restore the physiological drainage of the maxillary sinus. Conclusions: We decided to perform a combined intraoral and endoscopic approach to allow a complete excision of the cystic lesion, without being very demolishing and taking advantage of the bone erosion already caused by the large cyst.

Qualification of atypical squamous cells of undetermined significance in an independent laboratory: is it useful or significant?

OBJECTIVES: Correlation of cervical smears and biopsy samples emphasizes the significance of atypical squamous cells of undetermined significance as a diagnostic category. STUDY DESIGN: A retrospective study (October 1, 1995-March 21, 1997) was performed on all Papanicolaou smears diagnosed at DIANON Systems, Inc (Stratford, Conn). RESULTS: During this period 1551 patients with Papanicolaou smears had subsequent cervical biopsies performed within 90 days of cytologic sampling. There were 560 diagnoses of atypical squamous cells of undetermined significance. Tissue specimen results were positive in 203 cases (36.2%) and negative in 357 cases (63.8%). Of the positive biopsy results after a smear with atypical squamous cells of undetermined significance, 109 showed low-grade squamous intraepithelial lesions and 94 showed high-grade squamous intraepithelial lesions. CONCLUSIONS: This study, the largest cytologic and histologic correlation of atypical squamous cells of undetermined significance, demonstrates that a significant percentage of smears with atypical squamous cells of undetermined significance represent squamous intraepithelial lesions and that qualification of atypical squamous cells of undetermined significance as reactive or dysplastic is useful and should serve as a guide for patient management.

The appropriate lower limit for the percent free prostate-specific antigen reflex range.

OBJECTIVES: The ability of percent free prostate-specific antigen (PSA) to distinguish benign from malignant prostate disease has been established within the 4.0 to 20.0 ng/mL total PSA range, but its utility within the less than 4.0 ng/mL total PSA range has not been clearly defined. We undertook this study to determine the lower limit for the percent free PSA reflex range. METHODS: Four hundred seventy-nine men (mean age [+/-SD] 63.2 +/- 9.68 years) met the following criteria: (1) a measurable total serum PSA level of 4.0 ng/mL or less (mean 2.64 +/- 0.050); (2) concurrently measured free PSA and percent free PSA calculated (mean 19.3% +/- 0.59%); (3) a sextant biopsy diagnosed benign (B) (n = 376) or malignant (M) (n = 103), at one institution, within 90 days of serum collection; and (4) no prior history of prostate cancer. We defined the lower limit to be the lowest total PSA value at which (1) percent free PSA distributions differed between benign and malignant cases; and (2) percent free PSA could predict malignant disease. We compared age, total PSA, and percent free PSA differences with the Mann-Whitney U test and analysis of variance, and used univariate logistic regression to determine each variable's predictive value. Other statistical analysis was performed with contingency tables, Fisher's exact test, and linear regression. RESULTS: The lowest total PSA value at which percent free PSA both differed between benign and malignant cases and predicted prostate cancer was 4.0 ng/mL. CONCLUSIONS: The lower limit for the percent free PSA reflex range should be 4.0 ng/mL.

An algorithm combining age, total prostate-specific antigen (PSA), and percent free PSA to predict prostate cancer: results on 4298 cases.

OBJECTIVES: To (1) determine if patient age and total prostate-specific antigen (PSA) levels could enhance the ability of percent free PSA to distinguish prostate cancer from benign prostate disease within the 4.0 to 20 ng/mL total PSA range; (2) define the probability of prostate cancer based on patient age, total PSA, and percent free PSA; and (3) define a probability cutoff that distinguishes benign from malignant prostate disease. METHODS: The 3773 urologically referred patients with serum PSA values between 4.0 and 20 ng/mL had a sextant biopsy diagnosed as either prostatic carcinoma (1234) or benign prostatic disease (2539) within 60 days of serum specimen collection. We created a logistic regression model, using patient age, total PSA, and percent free PSA, to assign a probability of prostate cancer, and tested the model on an additional data set (525 patients) to calculate sensitivity and specificity. RESULTS: An 18% probability cutoff detected 95% of malignant biopsies and identified 34% of negative biopsies in the validation set. This approach yielded an 11% percentage point increase in specificity over percent free PSA alone. A 20% probability cutoff detected 90% of malignant cases and identified 42% of negative biopsies. CONCLUSIONS: A prostate cancer probability based on age, total PSA, and percent free PSA is more effective than percent free PSA alone in differentiating benign prostate disease from prostate cancer. This model may assist physicians and patients regarding the need for biopsy.

Accuracy of biopsy Gleason scores from a large uropathology laboratory: use of a diagnostic protocol to minimize observer variability.

OBJECTIVES: To examine the correlation of biopsy Gleason scores with radical prostatectomy specimens from a laboratory that uses protocols designed to minimize observer variability. This protocol mandates consensus case review of all nonbenign cases. METHODS: Between August 24, 1993 and June 26, 1997, 106 patients who underwent radical prostatectomy at Johns Hopkins Hospital, Baltimore, Maryland had their prostate cancer diagnosed and graded at one laboratory (DIANON Systems). We analyzed the Gleason scores from the biopsy and radical prostatectomy specimens. RESULTS: Exact correlation existed between biopsy and radical prostatectomy Gleason scores for 72 (68%) cases; 103 (97%) correlated within 1 grade, all cases correlated within 2 grades; 26 (25%) biopsies were undergraded and 8 (8%) were overgraded. Positive predictive values for biopsy Gleason scores 5, 6, and 7 were 66%, 67%, and 71%, respectively. Grouped Gleason scores (well differentiated [2 to 4], moderately differentiated [5, 6], moderately to poorly differentiated [7], and poorly differentiated [8 to 10]) correlated exactly for 74 (70%) cases and within 1 group for all cases. Patient age, digital rectal examination results, total number of positive cores, and maximum percentage of tumor on biopsy did not affect correlation, but prostate-specific antigen (PSA) levels did affect correlation (exact correlation 96% when the PSA level was less than 5 ng/mL; 50% when the PSA level was 11 ng/mL or greater, P <0.01). CONCLUSIONS: The combination of experience and the protocol described minimizes intra- and interobserver variability, thereby improving the predictive value of biopsy Gleason grading. Biopsy and radical prostatectomy Gleason scores correlate more poorly when the PSA level is high (11 ng/mL or greater) than when the PSA level is low (less than 5 ng/mL).