Faculty Bibliography

We present autopsy data from a patient that illustrates the anatomical factors that allow the esophagus to be a mobile structure, especially with respect to the posterior left atrial wall.

PURPOSE/OBJECTIVE:Historically estimating prostate volume by transrectal ultrasound underestimates actual prostate weight. We quantified and determined whether trends could be identified to predict or understand the underestimation. MATERIALS AND METHODS/METHODS:The characteristics transrectal ultrasound volume, pathological prostate weight and dimensions in 181 patients were entered into an electronic spread sheet. Pathological and transrectal ultrasound volume was estimated using the standard ellipsoid formula, width x height x length x pi/6. In 87 of the 181 cases transrectal ultrasound dimensions were compared to pathological dimensions. RESULTS:Using pathologically determined dimensions the ellipsoid formula accurately (+/-10%) predicted weight in 26.5% of the cases vs 13.3% by ultrasound. Transrectal ultrasound underestimated it by greater than 30% in 55% of cases and overestimated (greater than 10%) it in only 6.4%. Small vs large gland weight did not predict less underestimation. For prostate weight less than 30, 30 to 60 and more than 60 gm transrectal ultrasound underestimated by greater than 20% in 22.2%, 24.7% and 25.7% of cases, respectively. Paired analysis of transrectal ultrasound measurements and pathological dimensions revealed that transrectal ultrasound length was accurate (4.4 vs 4.3 cm) and had a good correlation with prostate weight. Height was underestimated (3.2 vs 3.7 cm) but it correlated with weight. Width was inaccurate (4.8 vs 5.2 cm) and it correlated poorly with weight. Age, prostate specific antigen, stage, Gleason score, American Urological Association symptom score and body mass index were not predictive of the underestimation. Displaced water volume in cc per prostate weight in gm showed a correlation of 0.997. CONCLUSIONS:The primary underlying factor for inconsistency with volume estimation of prostate weight appears to be the ellipsoid formula since pathologically determined dimensions still had a 75% error. Independent of gland size the transrectal ultrasound correlation underestimated weight 80% of the time by greater than 30% in 55% of patients. Contrary to previous reports, transrectal ultrasound width and not length is the least reliable factor.

Pulse granulomas are peculiar reactions to vegetable matter characterized by aggregates of hyaline rings and may be oral or extraoral. Pulse granulomas are important to recognize because they may indicate serious pathologic processes, may simulate neoplasia clinically, and may morphologically be confused with hyaline vasculopathy. We recently encountered a case involving a highly unusual pulse granuloma in a 55-year-old man who underwent prostatectomy for adenocarcinoma. Prior pancolonoscopy and digital rectal examination excluded significant colorectal disease. Microscopy showed a prominent pulse granuloma with demonstrable vegetable matter occupying periprostatic soft tissue. Interestingly, retrospective review of material from prior prostatic core biopsies revealed vegetable matter that appeared identical to the vegetable matter in the pulse granuloma. We conclude that the biopsies transrectally displaced vegetable matter, which provided the nidus for the pulse granuloma. We present the first pulse granuloma to be caused by a biopsy or to occupy periprostatic soft tissue.

OBJECTIVES/OBJECTIVE:The purpose of this study was to evaluate the role of caspase inhibitors on acute resolution of apoptosis in atherosclerotic lesions as evaluated by imaging with annexin A5. BACKGROUND:Extensive apoptosis of macrophages has been reported at the site of plaque rupture in patients dying of acute coronary syndrome. METHODS:Of 31 New Zealand White atherosclerotic rabbits, 6 received broad caspase, 3 received caspase-1, 3 received caspase-3, 3 received caspase-8, and 4 received caspase-9 inhibitors; 12 animals did not receive any caspase inhibitors (treatment control group). Six unmanipulated rabbits were used for comparison (disease control group). Technetium-99m-labeled annexin A5 was used for imaging atherosclerotic lesions; 6 of the 12 uninhibited atherosclerotic rabbits received (99m)Tc-labeled mutant annexin A5 (radiotracer control group). Gamma images were obtained, and quantitative radiotracer uptake was compared with pathologic findings. RESULTS:Atherosclerotic lesions were best visible in untreated atherosclerotic rabbits. Quantitative annexin uptake, defined as the percent of injected dose per g of abdominal aorta tissue, was significantly higher in untreated atherosclerotic animals (mean +/- SD = 0.0515 +/- 0.0099) compared with the normal rabbits (0.0065 +/- 0.0008; p < 0.0001) or atherosclerotic rabbits receiving mutant annexin (0.014 +/- 0.0024; p < 0.0001). Among all caspase inhibitor-treated rabbits, uptake was 39% lower (0.0314 +/- 0.0151) than in untreated atherosclerotic animals (p < 0.01). Uptake was also significantly lower in rabbits receiving broad caspase (0.0206 +/- 0.0058; p < 0.0001) or caspase-1, -3, or -9 (0.0272 +/- 0.0088, p < 0.01; 0.0286 +/- 0.0095, p < 0.01; 0.0300 +/- 0.0021, p < 0.01, respectively) inhibitors. Caspase-8 inhibitor did not affect apoptosis (0.0618 +/- 0.0047; p = NS). Upon histologic characterization, a substantial decrease in macrophage apoptosis was observed in caspase-inhibited animals. CONCLUSIONS:Molecular imaging, using radiolabeled annexin A5, allows the detection of acute resolution of apoptosis as a result of caspase inhibition in experimental atherosclerosis. If proven clinically, this may allow development of novel intervention strategies in acute vascular events.

INTRODUCTION/BACKGROUND:After exposure of the retropubic space, the surgeon commonly dissects the fat overlying the prostate and usually discards it. We have previously described the importance of dissecting this fat to completely visualize the dorsal venous complex (DVC) and prostatic apex. In this study, we describe a technique to dissect and remove the anterior prostatic fat pad (APF) and its anatomic and pathologic significance. TECHNICAL CONSIDERATIONS/METHODS:After the retropubic space was prepared, we dissected the fat overlying the puboprostatic ligaments and the DVC to fully expose these structures. The superficial branch of the DVC was then transected, and the fat was dissected cephalad to the junction with the bladder. The fat was then further dissected laterally toward the lateral pelvic sidewall. Video analysis of the lateral dissection of the fat revealed a direct link to the obturator lymph node chain, where it was transected. Pathologic analysis demonstrated that 30 (14.7%) of 204 patients had one or more APF lymph nodes, of which four were positive for metastatic prostate cancer. The cancer of 3 of these 4 patients was upstaged as a result of the detection of these positive nodes. CONCLUSIONS:The dissection of the APF facilitates visualization of the apex and bladder neck. Anatomically, we have demonstrated that the APF contains lymph nodes approximately 15% of the time that are in communication with the obturator lymph node chain and DVC. We found that removal of the APF and its pathologic analysis can result in pathologic upstaging.

Columnar cell lesion with atypia (CCLA) is a newly recognized pathologic entity seen in breast specimens. The breast cancer risk associated with this finding is unclear, although CCLA had been found adjacent to both in situ and invasive carcinomas, but the incidence is unknown. Breast specimens from patients with a columnar cell lesion were reviewed by a pathologist for atypia. Twenty-one specimens with CCLA were identified [core biopsy (8), excisional biopsy (11), and simple mastectomy (2)]. Six of eight specimens with CCLA on core had adjacent abnormal pathology: infiltrating ductal carcinoma (IDC)/lobular carcinoma in situ (LCIS) (1), ductal carcinoma in situ (DCIS)/LCIS (1), DCIS (1), LCIS (1), and papillomatosis (2). Five of 11 specimens with CCLA on excisional biopsy had adjacent abnormal pathology: IDC (3), DCIS/LCIS (1), and atypical ductal hyperplasia/papilloma (1). Two of two simple mastectomy specimens had CCLA associated with IDC (1) and DCIS (1). Overall, abnormal pathology was found adjacent to CCLA in 62 per cent of specimens (13/21). Breast pathologic specimens containing a columnar cell lesion should be carefully examined for atypia. Surgical excision is warranted for CCLA found on core biopsy. The future risk of breast cancer based on the finding of CCLA alone requires further investigation.

INTRODUCTION: We previously reported the benefit of meticulous apical dissection in reducing positive surgical margins (SM+) at the apex. Herein we assess whether a more aggressive urethral transection will reduce positive margins and whether reduced urethral length affects return to continence. TECHNICAL CONSIDERATIONS: All data were collected prospectively. A positive surgical margin was defined by the presence of cancer cells with ink on them. Continence, defined as no pads, was assessed with validated Expanded Prostate Cancer Instrument Composite questionnaires. Evaluation of 200 consecutive cases (group 1) revealed that 75% of surgical margins occurred at the apex. Concomitantly we assessed visual cues for urethral length, which demonstrated that even patients with very short urethral stumps requiring perineal pressure during anastomosis had equivalent times to continence as those with long, accessible stumps. We altered the point of transection, distally, to include 3 to 6 mm more of striated external urethral sphincter. The SM+ rate and time to continence for the ensuing 200 cases (group 2) were tracked. The overall SM+ and apical SM+ rates were significantly reduced (SM+ 17.6% versus 7.5%, P = 0.003; and apical SM+ 13% versus 5.5%, P = 0.01). Kaplan-Meier times to continence curves were not significantly different. CONCLUSIONS: A more aggressive apical resection resulted in marked reduction in overall SM+ rates without measurable change in time to continence or overall continence.