Faculty Bibliography

OBJECTIVE:To improve prostate cancer screening for high-risk men, we developed an early detection clinic for patients at high genetic risk of developing prostate cancer. Despite the rapidly growing understanding of germline variants in driving aggressive prostate cancer and the increased availability of genetic testing, there is little evidence surrounding how best to screen these men. METHODS:We are reporting on the first 45 patients enrolled, men between the ages of 35-75, primarily with known pathogenic germline variants in prostate cancer susceptibility genes. Screening consists of an intake lifestyle survey, PSA, DRE, and SelectMDx urine assay. A biopsy was recommended for any of the following indications: 1) abnormal DRE, 2) PSA above threshold, or 3) SelectMDx above threshold. The primary outcomes were number needed to screen, and number needed to biopsy to diagnose a patient with prostate cancer. RESULTS:Patients enrolled in the clinic included those with BRCA1 (n=7), BRCA2 (n=16), Lynch Syndrome (n=6), and CHEK2 (n = 4) known pathogenic germline variants. The median age and PSA were 58 (range 35-71) and 1.4 ng/ml (range 0.1-11.4 ng/ml), respectively. 12 patients underwent a prostate needle biopsy and there were 4positive biopsies for prostate cancer. CONCLUSION:These early data support the feasibility of opening a dedicated clinic for men at high genetic risk of prostate cancer. This early report on the initial enrollment of our long-term study will help optimize early detection protocols and provide evidence for personalized prostate cancer screening in men with key pathogenic germline variants.

Posterior reversible encephalopathy syndrome (PRES) is acute neurologic symptoms with specific radiologic findings. This unique case shows coexisting PRES with acute liver injury, which could suggest common pathophysiologic process.

BACKGROUND:The 2017 American College of Cardiology and American Heart Association guideline defined hypertension as blood pressure (BP) ≥ 130/80 mmHg compared to the traditional definition of ≥140/90 mmHg. This change raised much controversy. We conducted this study to compare the impact of tight (TBPC) versus standard BP control (SBPC) on the incidence of myocardial infarction (MI) and stroke. METHODS:We retrospectively identified all hypertensive patients in an ambulatory setting based on the diagnostic code for 1 year at our institution who were classified by the range of BP across 3 years into 2 groups of TBPC (< 130 mmHg) and SBPC (130-139 mmHg). We compared the incidence of new MI and stroke between the 2 groups across a 2-year follow-up. Multivariate analysis was done to identify independent predictors for the incidence of new MI and stroke. RESULTS:Of 5640 study patients, the TBPC group showed significantly less incidence of stroke compared to the SBPC group (1.5% vs. 2.7%, P < 0.010). No differences were found in MI incidence between the 2 groups (0.6% vs. 0.8%, P = 0.476). Multivariate analysis showed that increased age independently increased the incidence of both MI (OR 1.518, 95% CI 1.038-2.219) and stroke (OR 1.876, 95% CI 1.474-2.387), and TBPC independently decreased the incidence of stroke (OR 0.583, 95% CI 0.374-0.910) but not of MI. CONCLUSIONS:Our observational study suggests that TBPC may be beneficial in less stroke incidence compared to SBPC but it didn't seem to affect the incidence of MI. Our study is limited by its retrospective design with potential confounders.

Primary biliary cholangitis is associated with hyperlipidemia, but studies show that the condition does not increase cardiovascular risks. The case presents acute ischemic stroke with no underlying risk factors and subsequent new diagnosis of primary biliary cholangitis, which can suggest possible association between primary biliary cholangitis and acute stroke.

OBJECTIVE:To evaluate the association between midline prostatic cysts (MPCs) and lower urinary tract symptoms (LUTS). METHODS:A total of 606 patients who underwent transrectal ultrasound of the prostate (TRUS) were retrospectively reviewed. Patients were divided into two groups based on the presence of MPCs for comparison. We used the International Prostate Symptom Score (IPSS) as a LUTS parameter. Multivariate analysis was performed to find out independent predictors for moderate to severe LUTS. An MPC subgroup analysis was done to look for linear correlation between the size of MPCs and LUTS. RESULTS:Patients with no MPCs were of higher age, had more history of diabetes, were taking more urological medications, and had more IPSS storage symptoms. No significant differences were found in body mass index, total IPSS, voiding IPSS, bother score, total prostate-specific antigen level, and the prostate size. Multivariate analysis revealed age, history of diabetes, taking urological medications, and the prostate size as independent predictors of moderate to severe LUTS. The presence of MPCs was not an independent factor. Subgroup analysis failed to show significant correlation between the size of MPCs and the LUTS scores. CONCLUSIONS:The presence of MPCs is not an independent factor for moderate to severe LUTS, and the size of the MPCs does not have any correlation to LUTS scores either.

Hepatocellular carcinoma is one of the most common liver malignancies in the United States. Poor prognosis is associated with paraneoplastic syndromes such as hypercalcemia, hypercholesterolemia, or hypoglycemia. Hypercalcemia as a paraneoplastic syndrome of hepatocellular carcinoma has been rarely reported. We report a mortality case of incidentally diagnosed hepatocellular carcinoma associated with humoral hypercalcemia of malignancy. The patient demonstrated a fulminant disease course with an unexpected fatal outcome within 40 days of initial diagnosis. Our case can suggest importance of early definitive treatment of hepatocellular carcinoma, extremely close monitoring, and aggressive medical treatment when it is associated with humoral hypercalcemia of malignancy.

Systemic sclerosis, or scleroderma, is a complex medical disorder characterized by limited or diffuse skin thickening with frequent involvement of internal organs such as lungs, gastrointestinal tract, or kidneys. Docetaxel is a chemotherapeutic agent which has been associated with cutaneous side effects. An uncommon cutaneous side effect of docetaxel is scleroderma-like skin changes that extend from limited to diffuse cutaneous systemic sclerosis. Several case reports have been published regarding the association of docetaxel and systemic sclerosis. However, those reports demonstrated the association between docetaxel and scleroderma-like skin changes without internal organ involvement. Here, we report a case of systemic sclerosis with pulmonary arterial hypertension and a microangiopathic kidney involvement induced by docetaxel chemotherapy. After an exhaustive literature review, this could be the first case of docetaxel-induced systemic sclerosis involving internal organs.

Prostatic calculi are a common finding on transrectal prostate ultrasound. However, it remains unclear whether they are significantly associated with lower urinary tract symptoms (LUTS). Our objective was to evaluate the association between prostatic calculi and LUTS with a focus on "calculi burden" because no studies have investigated prostatic calculi using "calculi burden" as an indicator. A total of 606 participants who received transrectal prostate ultrasound were divided into two groups according to the presence of prostatic calculi. "Calculi burden" was defined as the sum of the transverse diameters of all visible calculi within the prostate. The International Prostatic Symptom Score (IPSS) and a quality of life (QoL) score were collected. Both groups were compared, and a multivariate analysis was performed to predict moderate/severe LUTS. Linear correlation was evaluated between calculi burden and IPSS in the calculi group. No differences in total IPSS, voiding IPSS, or QoL score were detected between the two groups, but storage IPSS was significantly higher in the calculi group than that of controls. The multivariate analysis showed that the presence of prostatic calculi was not an independent predictor of moderate/severe LUTS. A positive linear correlation was detected between calculi burden and storage IPSS in calculi group (r = 0.148). However, no correlation was found between calculi burden and total IPSS, voiding IPSS, or QoL score. Our results showed that the presence of prostatic calculi was not a significant factor predicting moderate/severe LUTS. However, an increased calculi burden may be associated with aggravating storage symptoms.

PURPOSE/OBJECTIVE:To retrospectively compare re-biopsy with preceded magnetic resonance imaging (MRI) and re-biopsy without preceded MRI. MATERIALS AND METHODS/METHODS:Between January 2007 and May 2011, 669 patients (mean 64 years; range 38-91 years) underwent a re-biopsy because of previous negative biopsy (median 1; 1-5) and persistently high prostate-specific antigen (PSA 10.6 ng/ml; 2.5-997.1 ng/ml). 3T MRI using a phased-array coil was performed in 171 (MRI group) but not in 498 (non-MRI group) prior to re-biopsy. Transrectal ultrasound-guided biopsy was performed in both MRI and non-MRI groups. MRI and non-MRI groups were compared in terms of cancer detection rate [(number of cancer-proven patients/number of patients in MRI or non-MRI group) × 100] and positive core rate [(number of cancer-positive cores/number of cores in MRI or non-MRI group) × 100] using Fisher exact test. Odds ratio and 95% confidence interval were also obtained. Pathologic diagnosis of the biopsy was considered standard reference. RESULTS:Of 669 patients, 129 (19.3%) were diagnosed with adenocarcinoma. The cancer detection rates of MRI and non-MRI groups were 33.3% (57/171) and 14.5% (72/498), respectively (p < 0.001). The positive core rates of these groups were 9.2% (167/1 818) and 3.2% (179/5 631), respectively (p < 0.001). The odd ratios of cancer detection rate and positive core rate were 3.0 (95% confidence interval 2.0-4.4) and 3.1 (2.5-3.8), respectively. CONCLUSION/CONCLUSIONS:Re-biopsy with preceded MRI yields higher cancer detection rate and positive core rate than re-biopsy without preceded MRI. MRI should be considered prior to re-biopsy in patients with previous negative biopsy and persistently high PSA.

Traditionally, urologists recommend an interval of at least 4 weeks after prostate biopsy before radical prostatectomy. The aim of our study was to evaluate whether the interval from prostate biopsy to radical prostatectomy affects immediate operative outcomes, with a focus on differences in surgical approach. The study population of 1,848 radical prostatectomy patients was divided into two groups according to the surgical approach: open or minimally invasive. Open group included perineal and retropubic approach, and minimally invasive group included laparoscopic and robotic approach. The cut-off of the biopsy-to-surgery interval was 4 weeks. Positive surgical margin status, operative time and estimated blood loss were evaluated as endpoint parameters. In the open group, there were significant differences in operative time and estimated blood loss between the <4-week and ≥4-week interval subgroups, but there was no difference in positive margin rate. In the minimally invasive group, there were no differences in the three outcome parameters between the two subgroups. Multivariate analysis revealed that the biopsy-to-surgery interval was not a significant factor affecting immediate operative outcomes in both open and minimally invasive groups, with the exception of the interval ≥4 weeks as a significant factor decreasing operative time in the minimally invasive group. In conclusion, performing open or minimally invasive radical prostatectomy within 4 weeks of prostate biopsy is feasible for both approaches, and is even beneficial for minimally invasive radical prostatectomy to reduce operative time.