Faculty Bibliography

BACKGROUND: Increasing evidence supports the use of magnetic resonance imaging (MRI)-ultrasound fusion-targeted prostate biopsy (MRF-TB) to improve the detection of clinically significant prostate cancer (PCa) while limiting detection of indolent disease compared to systematic 12-core biopsy (SB). OBJECTIVE: To compare MRF-TB and SB results and investigate the relationship between biopsy outcomes and prebiopsy MRI. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of a prospectively acquired cohort of men presenting for prostate biopsy over a 26-mo period. A total of 601 of 803 consecutively eligible men were included. INTERVENTIONS: All men were offered prebiopsy MRI and assigned a maximum MRI suspicion score (mSS). Men with an MRI abnormality underwent combined MRF-TB and SB. OUTCOMES: Detection rates for all PCa and high-grade PCa (Gleason score [GS] >/=7) were compared using the McNemar test. RESULTS AND LIMITATIONS: MRF-TB detected fewer GS 6 PCas (75 vs 121; p<0.001) and more GS >/=7 PCas (158 vs 117; p<0.001) than SB. Higher mSS was associated with higher detection of GS >/=7 PCa (p<0.001) but was not correlated with detection of GS 6 PCa. Prediction of GS >/=7 disease by mSS varied according to biopsy history. Compared to SB, MRF-TB identified more GS >/=7 PCas in men with no prior biopsy (88 vs 72; p=0.012), in men with a prior negative biopsy (28 vs 16; p=0.010), and in men with a prior cancer diagnosis (42 vs 29; p=0.043). MRF-TB detected fewer GS 6 PCas in men with no prior biopsy (32 vs 60; p<0.001) and men with prior cancer (30 vs 46; p=0.034). Limitations include the retrospective design and the potential for selection bias given a referral population. CONCLUSIONS: MRF-TB detects more high-grade PCas than SB while limiting detection of GS 6 PCa in men presenting for prostate biopsy. These findings suggest that prebiopsy multiparametric MRI and MRF-TB should be considered for all men undergoing prostate biopsy. In addition, mSS in conjunction with biopsy indications may ultimately help in identifying men at low risk of high-grade cancer for whom prostate biopsy may not be warranted. PATIENT SUMMARY: We examined how magnetic resonance imaging (MRI)-targeted prostate biopsy compares to traditional systematic biopsy in detecting prostate cancer among men with suspicion of prostate cancer. We found that MRI-targeted biopsy detected more high-grade cancers than systematic biopsy, and that MRI performed before biopsy can predict the risk of high-grade cancer.

Background Parathyromatosis, described as hyperfunctioning, benign parathyroid tissue scattered throughout the soft tissues of the neck, is a rare cause of recurrent hyperparathyroidism. Fewer than 40 cases have been described in the literature. We describe a case of a woman with recurrent hypercalcemia secondary to parathyromatosis; additionally this is the first reported case of a papillary pattern in parathyromatosis. Clinical Case A 45 year old woman with a history of a left parathyroid adenoma, status post focused parathyroidectomy 10 years ago, presented with constipation, polyuria and abdominal pain. Initial examination demonstrated a well healed cervical scar with no palpable neck masses. Admission laboratory findings were significant for a calcium level of 13.6 mg/dL (n 8-10.4 mg/dL) , ionized calcium 7.7 mg/dL (n 4.6-5.2 mg/dL), phosphorus 2.2 mg/dL (n 2.7-4.5 mg/dL), 25 OH-vitamin D 9.6 ng/mL (n 30-100 ng/mL), PTH 395 pg/mL (n 14-72 pg/mL), PTHrP <0.7 pmol/L (n <2.0 pmol/L) and urine calcium 484 mg/24 hr (n 50-250 mg/24hr). No obvious enlarged parathyroid was localized on neck ultrasound or sestamibi scan. Neck CT showed two 6 mm nodular lesions in the upper mediastinum. The patient had refractory hypercalcemia despite maximal medical therapy. She was taken to the operating room for reoperative neck exploration. She was noted to have diffuse exophytic fronds of tissue covering her left thyroid lobe, which prompted removal of the lobe. Intraoperative PTH decreased from 454 pg/mL to 39 pg/mL. Microsopic examination demonstrated multifocal hypercellular parathyroid nodules in skeletal muscle and perithyroid adipose tissue consistent with parathyromatosis. An unusual pathologic finding was its unique papillary configuration, raising consideration for a parathyroid carcinoma on frozen section. Final pathology confirmed parathyromatosis with no features of carcinoma (vascular invasion, fibrosis or high mitotic activity) with diffuse immunohistochemical reactivity for PTH and non-reactivity for Thyroid Transcription Factor-1. The patient's calcium level was normal post operatively (9.2 mg/dL) with resolution of symptoms. Conclusion Parathyromatosis is a rare disease that raises challenges in diagnosis and management. Preoperative localization of parathyromatosis is difficult, leading to a high surgical failure rate. Scarring and fibrosis from previous neck exploration leads to technical difficulty, since the most common cause for parathyromatosis is seeding of hypercellular parathyroid tissue during previous parathyroidectomy. Medical management is essential during the post-operative period to maintain a normocalcemic state. Our case presents with a pathologic finding of papillary pattern in parathyromatosis, which has not been previously described and can pose a diagnostic challenge in separation from papillary carcinoma on frozen section examination

Retroperitoneal schwannoma is a rare tumor that is often misdiagnosed as malignancy due to a concerning appearance on cross-sectional imaging. Pathology and immunohistochemistry form the gold standard for diagnosis; as such, local excision is the treatment of choice for this disease. We present two cases of juxta-adrenal ancient schwannoma that were treated with adrenalectomy and discuss the current literature regarding this entity.