Perineal Biopsy Research Articles

Perineal prostate biopsy

The prostate biopsy is an essential tool for diagnosing prostate cancer (PCa). While transrectal biopsy (TR-Bx) continues to be considered the gold standard in Germany, the European Association of Urology (EAU) guidelines increasingly recommend transperineal biopsy (TP-Bx) due to lower infection rates and higher tumor detection rates. This article provides an overview of the history and development of the perineal biopsy, compares TR-Bx and TP-Bx and discusses the need for antibiotic prophylaxis before TP-Bx. Current studies have shown that TP-Bx can be performed without antibiotic prophylaxis and new techniques such as robotic-assisted and vector biopsy show very precise results. The establishment of TP-Bx is being promoted by extrabudgetary funding and technological advancements, with the choice of biopsy method remaining an individual decision jointly made in dialogue with the patient.

Salvage high-dose rate brachytherapy for local recurrence of prostate cancer after radical prostatectomy

Background. The current need for optimization of salvage treatment methods is dictated by the growing expansion of indications for radical prostatectomy in many centers in the developed countries of the world.Aim. To evaluate the effectiveness, toxicity, and technical characteristics of high-dose rate brachytherapy in treatment of local prostate cancer (PCa) recurrences after radical prostatectomy.Materials and methods. Between January 2015 and December 2020, salvage high-dose rate brachytherapy was performed in 17 patients at the Russian Scientific Center of Roentgenology and Radiology for local recurrence of PCa after radical prostatectomy. All patients underwent multiparametric magnetic resonance imaging of the pelvis at the stage of primary diagnosis in order to determine macroscopic tissue component in the prostate bed area. To rule out regional and distant metastases, all patients underwent positron emission tomography with 18F- or 68Ga-labeled prostate-specific membrane antigen. All patients included in the study underwent perineal biopsy of the prostate bed and seminal vesicles.Results. Median follow-up in the treatment group was 35.7 (24–54) months. Overall survival was 100 %. Prostatespecific antigen-specific survival was 88.2 %. There were no local recurrences of PCa in the treatment group. In patients with local PCa recurrence, significant predictors of treatment failure were the presence of clinically extremely high risk of progression at initial diagnosis (p = 0.003), development of biochemical relapse up to 24 months after main treatment (p = 0.001), and increased blood level of prostate-specific antigen above 10 ng/mL during registration of biochemical relapse (p = 0.002).Conclusion. High-dose rate brachytherapy is a safe and effective salvage treatment for local recurrence of PCa after radical prostatectomy. In addition to the brachytherapy technique, the diagnostic stage is also of great importance providing visualization of the exact location of tumor recurrence.

460 Prostate Biopsy Sepsis Rates – Are We Meeting National Average Levels?

Abstract Aim To identify the prevalence of sepsis following trans rectal ultrasound (TRUS) biopsy of the prostate at our unit and identify potential causes for this, and to implement change to reduce the sepsis rate. Method A retrospective observational audit was performed between 01/10/19–17/01/20 for TRUS biopsy, followed by two re-audits between 05/03/20–28/05/20 and 06/08/20–17/09/2020 for trans perineal (TP) biopsy. A descriptive statistical analysis was performed on the data as well as an N-1 Chi-squared test on the data with a p<0.05 set as statistically significant. We compared our procedure to the BAUS guideline and NICE guideline for TRUS and TP biopsy. Results A total of 202 patients had TRUS biopsies between 01/10/19 to 17/01/20. 7.9% of patients presented with sepsis following their biopsy. Following our recommendation, between 05/03/20 to 28/05/20, a total of 19 patients had TP biopsy at our unit with 0 developing sepsis. A re-audit of 44 patients who underwent TP biopsy between 06/08/20 to 17/09/2020 showed no patients developing sepsis, indicating sustained improvement. Conclusion The rate of TRUS biopsy sepsis was four times higher than average levels at our department. There were zero patients who became septic following their TP biopsy. Over a 3-month period our TRUS biopsy audit showed 69 days of sepsis related admission, this is greater than £30,000 in costs. TP biopsy therefore leads to improved patient experiences with their care and also a significant cost saving to the trust.

Transperineal prostate biopsies without antibiotic prophylaxis: Safety evaluation of the first 65 patients.

355 Background: There is an ongoing trend towards perineal prostate biopsies for the detection of prostate cancer. For many reasons the issue of antibiotic prophylaxis in prostate biopsies is becoming more important, especially with quinolone antibiotics being excluded from this indication and an increasing antibiotic resistance. Considering that the perineal biopsy is a sterile procedure, not giving antibiotics for prophylaxis seems to be an alluring approach. Methods: At the General Hospital Leverkusen, transperineal (TP) MRI TRUS fusion biopsies are performed using the Ginsburg Protocol with a template and software-guided approach in general anesthesia. Patients received single dose antibiotics (Ciprofloxacine 500 mg) two hours prior to surgery from Jan 2019 to Aug 2019 (group 1). Starting in Sep 2019, no antibiotics were used for prophylaxis (group 2). Surgical disinfection using Povidone-iodine was performed ahead of every procedure. In this study, postoperative infection rates were assessed. Patients were followed up by telephone interview at least two weeks after biopsy and were asked about the need for postoperative antibiotics to treat regular UTI, fever, prostatitis or for readmission to other hospitals. Results: A total of 180 TP biopsies were performed with a median of 22 cores (min 18, max 28). Out of 115 cases with antibiotic prophylaxis, no patient was readmitted to the hospital due to infection or fever. Group 2 included 65 patients. No one was readmitted with fever or prostatitis. At the time of abstract admission 45 out of 65 patients in this group were followed up by telephone interview. None needed antibiotics and none was readmitted to a hospital elsewhere. Conclusions: The study shows an infection rate of 0 % for perineal prostate biopsies with or without antibiotic prophylaxis. The results argue in favor of perineal prostate biopsies and challenge the dogma of prostate biopsies needing an antibiotic prophylaxis irrespective of the approach. However, a larger prospective multicenter study should be initiated to ensure patient safety.

Comparative analysis of adverse events using different methods of prostate biopsy

Background . The indicator of detected cases of prostate cancer (PCa) in 2015 was 38,812. The standardized incidence rate was 40.23per 100,000population. Increase in the incidence of PCa from 2005 to 2015 — 135.5 %. The average annual growth rate is 7.76 %. The histological verification of PCa is of great importance in the diagnosis and subsequent choice of treatment tactics. Currently, the most common method of transrectal “blind” prostate biopsy is to control the control, which does not have sufficient sensitivity and specificity for detecting PCa, and the morphological result contains limited information about the aggressiveness and stage of cancer. In connection with the development of modern methods of magnetic resonance diagnostics, such as multiparametric magnetic resonance imaging, which is currently the most sensitive and specific imaging method for the diagnosis of PCa, methods of targeted prostate biopsy are increasingly used in clinical practice. Scientific work supports the rapidly growing use of multiparametric magnetic resonance imaging (MRI) as the most sensitive and specific imaging tool for detection, lesion characterisation and staging of PCa. Objective is to the safety and frequency of complications of transperineal, transrectal, MRI/TRUS (magnetic resonance imaging/transrectal ultrasound) fusion targeted-biopsy. Materials and methods. The fusion of magnetic resonance imaging data with transrectal ultrasound enables the targeted biopsy of suspicious areas. 142 consecutively selected patients were examined, mean age of 62.0 + 6.5 years. According to aim we assigned patients to 3 groups: 1 st group (n = 49) underwent repeated transrectal biopsy of the prostate; in patients of 2 nd group (n = 39) perineal biopsy of the prostate; in 3 rd group there were patients (n = 54) a targeted fusion biopsy with magnetic resonance imaging and transrectal ultrasound-navigation. Results. PCa was diagnosed in 26.5, 46.2 and 61.1 % respectively. The most frequent complication of biopsy of the prostate gland was hematuria. This symptom was found in 33.3 % patients of the 1 st group, 42.5 % in the 2 nd group and 42.2 % in the 3 rd group. The prolongation of hospitalization due to hematuria was required by 5patients (11.9 %) from 1 st group, 8 (17.0 %) from 2 nd and 5 (7.8 %) from group 3. Hospitalization and additional treatment was required in 8 (16.3 %) patients in 1 st group and 1 (2.5 %) in 2 nd group. Infectious-inflammatory complications are often diagnosed and require additional treatment. In 1 st group patients, this type of complication was observed in 16.3 %, 2 nd and 3 rd groups 5.1 % and 1.9 %, respectively. In 4.7 % of the patients in the 1 st group, sepsis was diagnosed, complications were not recorded in patients of groups 2 nd and 3 rd of the data group. When assessing the complications, there was a slight predominance of the complication rate of the standard transrectal biopsy procedure, but this difference was statistically insignificant (p >0.05). Conclusion . We compared the security of standard biopsy and perineal biopsy to diagnose PCa against a novel approach using software to overlay the images from magnetic resonance imaging and ultrasound to guide biopsies towards the suspicious areas of the prostate. We found consistentfindings showing the superiority of this novel targeted approach, although further high-quality evidence is needed to change current practice. No significant statistical differences were found in the complications rates between.

Diagnostic Performance of Multiparametric Magnetic Resonance Imaging and Fusion Targeted Biopsy to Detect Significant Prostate Cancer.

Multiparametric magnetic resonance imaging combined with ultrasound-fusion-targeted biopsy of the prostate intends to increase diagnostic precision, which has to be clarified. We performed multiparametric magnetic resonance imaging followed by ultrasound-fusion-guided perineal biopsy in 99 male patients with elevated prostate-specific-antigen and previous negative standard biopsy-procedures. In 33/99 patients (33%) no malignancy could be confirmed by histopathology. Low-grade carcinomas (Gleason-Score 6+7a) were found in 42/66 (64%) and high-grade carcinomas (Gleason-Score ≥7b) in 24/66 (36%) men. A high-grade carcinoma corresponded to PI-RADS 4 or 5 (suspected malignancy) in 21/24 cases, which accounted for a sensitivity of 88% and negative-predictive-value of 85% (p=0.002). Differentiation between high-/low-grade carcinomas (Gleason-Score ≤7a vs. ≥7b) by means of PI-RADS related to a sensitivity of 88% and a negative-predictive-value of 70% (p=0.74). The results support the view that multiparametric magnetic resonance imaging/ultrasound-fusion-guided biopsy promotes considerably higher detection rates of clinically relevant prostate malignancies than do conventional diagnostic procedures. With regard to differentiation between high- and low-grade carcinomas, no significant difference was demonstrated.

FUSION PROSTATE BIOPSY IN PATIENTS WITH PREVIOUS NEGATIVE STANDARD PROSTATE BIOPSY

Introduction . Prostate cancer is one of the common oncological diseases in men. Standard prostate biopsy with subsequent histological verification is now an integral part of the diagnosis of prostate cancer; however, the number of false-negative results and cases of underestimation of the degree of tumor aggressiveness remain excessively high. Advances in multiparametric magnetic resonance imaging have lead to improved detection of prostate tumors. Objective . Disclosure of the main advantages of prostate biopsy under the magnetic resonance imaging control, consideration of technical aspects of its implementation. Materials and methods . The fusion of magnetic resonance imaging data with transrectal ultrasound enables the targeted biopsy of suspicious areas. 136 consecutively selected patients were examined, mean age of 62 years, mean prostate volume was 53 cm3, the average prostate-specific antigen 11.3 ng/ml. All the patients underwent at least 1 transrectal prostate biopsy. We assigned patients into 3 groups: group 1 (n=43) underwent repeated standard transrectal biopsy of the prostate; in group 2 (n=39) patients had transperineal biopsy of the prostate; in group 3 there were patients (n=39) in whom a targeted fusion biopsy with magnetic resonance imaging and transrectal ultrasound - navigation has been performed. An average number of biopsy cores in each group was 12, 26.6 and 25.3, respectively. Results . Prostate cancer was diagnosed in 30.2%, 53.7 % and 56.4 % respectively. Better prostate cancer detectability during fusion biopsy generally occurred due to the localized forms of the disease (93.3 %). Conclusion . Fusion biopsy using magnetic resonance imaging and transrectal ultrasound and perineal biopsy allows precise determination of prostate cancer pathological stage, Gleason grade of a tumor and its exact localization. Most tumors detectable by saturation perineal biopsy and fusion biopsy using magnetic resonance imaging and transrectal ultrasound were clinically significant, which makes it possible to recommend these methods of biopsy to patients with a high level of suspicion for prostate cancer.

Response to Editorial Comment to Combination of lidocaine suppository and periprostatic nerve block during transrectal prostate biopsy: a prospective randomized trial.

We thank Dr Salagierski for his critical comments. Please find the responses to your questions below: 1 What might have been the mechanism of pain reduction by combined anesthesia during the sampling part of the prostate biopsy? 2 Was there an age-related difference in the perception of pain? 3 What was the reason for including patients undergoing subsequent prostate biopsy? We want to clarify that in our opinion, the mechanism of pain reduction during sampling is in large part due to the synergistic effect of neurovascular bundle blockage aided by the lidocaine suppository that can reduce sensation in the anal canal. Above the dentate line there is no sensory innervation, resulting in less discomfort of the transrectal probe in the anal canal, especially for the apical biopsies requiring more erect of the probe. The age-related difference in the perception of pain was more conspicuous in the single substance group. No difference was detectable within group 3 (periprostatic nerve block and lidocaine suppository). The reason for including patients with subsequent biopsies was to show that, specifically in group 3, pain reduction was clearly better than that during the previous biopsies. The comment by Dr Salagierski on the general use of local anesthesia can only be supported. In our experience, there are still patients receiving prostate biopsies without any form of analgesia. This must not be carried out today, and is clearly obsolete. In our series, periprostatic injections, particularly around the area of the apex, without a lidocaine suppository were uncomfortable for the majority of the patients. In Hanusch Krankenhaus, Vienna, Austria, every patient undergoing a prostate biopsy receives combination therapy and has excellent outcomes. Even patients who underwent a re-biopsy under the same conditions were not worried. We recommend the combination of a lidocaine suppository and periprostatic nerve block, even in extended biopsies. The use of general anesthesia for prostate biopsies is indicated in perineal and/or saturation biopsies, but cannot be recommended for the large majority of men. Not only because of costs, but also the possible risks of general anesthesia, we believe that any form of sufficient local anesthesia should be recommended for the comfort of the patient and the time schedule of the procedure.

From skid row to Main Street: the Bowery series and the transformation of prostate cancer, 1951-1966.

Between 1951 and 1966, more than twelve hundred homeless, alcoholic men from New York's skid row were subjected to invasive medical procedures, including open perineal biopsy of the prostate gland. If positive for cancer, men typically underwent prostatectomy, surgical castration, and estrogen treatments. The Bowery series was meant to answer important questions about prostate cancer's diagnosis, natural history, prevention, and treatment. While the Bowery series had little ultimate impact on practice, in part due to ethical problems, its means and goals were prescient. In the ensuing decades, technological tinkering catalyzed the transformation of prostate cancer attitudes and interventions in directions that the Bowery series' promoters had anticipated. These largely forgotten set of practices are a window into how we have come to believe that the screen and radical treatment paradigm in prostate cancer is efficacious and the underlying logic of the twentieth-century American quest to control cancer and our fears of cancer.

"Screening" for prostate cancer in New York's skid row: history and implications.

The Bowery series, open perineal biopsies performed on more than 1200 alcoholic men recruited from homeless shelters in New York City's Bowery section, began in 1951 and persisted for more than a decade. If frozen sections revealed prostate cancer, men typically underwent radical perineal prostatectomy, orchiectomy, and diethylstilbestrol treatment. This poorly informed, vulnerable population was subjected to health risks that investigators knew others would not accept. Although the knowledge produced had little impact on practice, the Bowery practices foreshadowed and have troubling continuities with later developments. Currently, more than a million American men each year undergo prostatic biopsies. But the efficacy of prostate-specific antigen screening and the treatment that typically follows has never been established. The Bowery series and subsequent developments are part of one continuous story of how medical and lay people came to believe in the efficacy of population screening followed by aggressive treatment without solid supporting scientific evidence.

Computer-aided (HistoScanning) Biopsies Versus Conventional Transrectal Ultrasound-guided Prostate Biopsies: Do Targeted Biopsy Schemes Improve the Cancer Detection Rate?

To define potential improvement in prostate cancer detection by application of a computer-aided, targeted, biopsy regimen using HistoScanning. We analyzed 80 patients who underwent systematic transrectal, targeted transrectal, and targeted perineal biopsies. Each patient was diagnosed preoperatively by HistoScanning, defining a maximum of 3 suspicious areas. These areas were biopsied, both transrectally and via the perineum, with a maximum of 3 cores per location. We detected prostatitis in 30 patients (37.5%), premalignant lesions in 10 (12.5%), and prostate cancer in 28 (35%). The transrectal technique was used to detect 78.6% of all cancers using 14 cores by systematic biopsy. With a maximum of 9 targeted cores, 82.1% of all cancers were detected with the targeted perineal approach and 53.6% were detected with the targeted transrectal approach. Although our data did not show significant difference in the performance of targeted transperineal compared with systematic transrectal biopsies, the detection rate of targeted transrectal biopsies was significantly lower. The presented targeted biopsy scheme achieved an overall detection rate of 85% of prostate-specific antigen-relevant pathologic lesions within the prostate. Thus, the presented procedure shows an improved detection rate compared with standard systematic prostate biopsies, and the number of cores required is reduced. Furthermore, the perineal HistoScanning-aided approach seems to be superior to the transrectal approach with respect to the prostate cancer detection rate. The presented procedure might be a step toward reliable ultrasound-based tissue characterization and toward fulfilling the requirements of novel therapeutic strategies.

Perineal Pyoderma Gangrenosum in a Patient with Inflammatory Bowel Disease

Purpose: Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by necrotic, violaceous ulcers that follow an aggressive, painful, and debilitating course. Lesions usually affect the lower extremities, but often involve other cutaneous regions, such as peristomal tissues. Identifying atypical PG in unusual locations is difficult as the diagnosis is one of exclusion. The differential diagnosis for perineal ulcers includes hidradenitis suppurativa, ecthyma gangrenosum, herpes simplex, cutaneous Crohn's disease, cutaneous tuberculosis, cutaneous lymphoma, vasculitis, lichen planus, and autoimmune blistering conditions. We describe a 60-year-old man with ulcerative colitis (UC) without prior extraintestinal manifestations who was post-colectomy for dysplasia and presented with perineal dermatosis 5 months after ileostomy closure. His post-operative course was marked by frequent bowel movements with urgency, tenesmus and subsequent perineal irritation. Despite local therapy and oral antibiotics, his perineal irritation progressed to excoriations, and then exquisitely painful ulcerations. He was then admitted and evaluated by a multidisciplinary team including gastroenterology, dermatology, infectious diseases and colorectal surgery. Minimal enteric inflammation limited to the pouch was seen on endoscopy and histopathology. Perineal biopsy showed non-specific neutrophilic inflammatory infiltrate. Wound cultures grew Pseudomonas aeruginosa. He was placed on IV antibiotics for possible ecthyma gangrenosum. After five days of nonresponse, it was felt that his lesions represented PG despite the indolent perineal disease course. IV steroids were added with no effect, and IV cyclosporine was then started with dramatic improvement over the next 2 weeks and resolution after 2 months on oral cyclosporine. Interestingly, the patient's gastrointestinal symptoms also began to subside. An outpatient pouchoscopy for recurrent diarrhea with pain on defecation revealed deep stellate lesions in the distal pouch, and the patient's IBD diagnosis was changed to Crohn's disease. The PG remained quiescent. He was transitioned from cyclosporine to infliximab. Atypical presentations of PG are a diagnostic dilemma for clinicians, and a broad differential diagnosis must be entertained, especially in IBD patients. We report here the first case in the literature of perineal PG in an adult IBD patient.Figure: No Caption available.

A case of juvenile xanthogranuloma involving skin and multiple systemic organs in a fetus

Juvenile xanthogranuloma is a benign histiocytic proliferative disorder. It typically presents as a solitary, benign, rapidly growing cutaneous tumor that may regress spontaneously. Most of juvenile xanthogranuloma occur in infants and young children. We had experienced a case of juvenile xanthogranuloma in a fetus which involves multiple systemic organs. On prenatal ultrasonography, the fetus presented with pulmonary, perineal and hepatic nodules. The neonate was diagnosed with juvenile xanthogranuloma by the cutaneous and perineal nodule biopsy after birth. The neonate outpatient follow-up shows spontaneous regression without specific treatment. So we report a case with a brief review of the literature.

A Novel Stereotactic Prostate Biopsy System Integrating Pre-Interventional Magnetic Resonance Imaging and Live Ultrasound Fusion

We developed an effective way to precisely diagnose prostate cancer using a novel prostate biopsy system that integrates pre-interventional magnetic resonance imaging with peri-interventional ultrasound for perineal navigated prostate biopsy. A total of 106 men with findings suspicious for prostate cancer (median age 66 years, prostate specific antigen 8.0 ng/ml and prostate volume 47 ml) underwent multiparametric 3 Tesla magnetic resonance imaging. Suspicious lesions were marked and data were transferred to the novel biopsy system. Using a custom-made biplane transrectal ultrasound probe mounted on a stepper we gathered 3-dimensional ultrasound data and fused them with magnetic resonance imaging data. As a result, suspicious magnetic resonance imaging lesions were superimposed over the transrectal ultrasound data. Three-dimensional biopsy planning was done, including systematic biopsies. Perineal biopsies were taken under live ultrasound guidance and the precise site of each biopsy was documented in 3 dimensions. We evaluated feasibility, safety and cancer detection. Prostate cancer was detected in 63 of 106 patients (59.4%). Magnetic resonance imaging findings correlated positively with histopathology in 71 of 103 patients (68.9%). In magnetic resonance imaging lesions marked as highly suspicious, the detection rate was 95.8% (23 of 24 cases). Lesion targeted cores had a significantly higher positivity rate than nontargeted cores. The procedural targeting error of the first 2,461 biopsy cores was 1.7 mm. Regarding adverse effects, 2 patients experienced urinary retention and 1 had a perineal hematoma. Urinary tract infections did not develop. Perineal stereotactic prostate biopsies guided by the combination of magnetic resonance imaging and ultrasound enable effective examination of suspicious magnetic resonance imaging lesions. Each biopsy core taken is documented accurately for its location in 3 dimensions, enabling magnetic resonance imaging validation and tailored treatment planning. The morbidity of the procedure was minimal.

2304 STEREOTACTIC PROSTATE BIOPSY WITH PRE-INTERVENTIONAL MRI AND LIVE US FUSION

INTRODUCTION AND OBJECTIVES: The key challenge for focal therapy of prostate cancer is to identify index lesions. In this context, we describe our initial experience with a new stereotactic prostate biopsy system, which integrates pre-interventional MRI data with periinterventional ultrasound for perineal prostate biopsies. METHODS: 33 patients were stereotactically biopsied (mean age of 64yrs., mean PSA level of 8.2ng/ml and mean prostate vol. of 40ml). 21 of these 33 patients had already had a negative transrectal US-guided biopsy. All men underwent multimodal 3 Tesla MRI without endorectal coil including diffusion weighted imaging and dynamic contrast enhanced sequences as well as MR-spectroscopy. Suspicious lesions were marked by radiologists with over 10 years experience in reading prostate MRI before the obtained data were transferred to the stereotactic biopsy system. Using a custom-made biplane TRUS probe mounted on a stepper device, 3D ultrasound data were generated to set the anatomic landmarks. Then MRI and TRUS imaging data were fused manually. As a result, the suspicious MRI lesions were superimposed onto the TRUS data. Next, 3D biopsy planning was performed including systematic biopsies from the peripheral and transitional zones of the prostate. Perineal biopsies were taken under live US imaging, and the location of each biopsy was documented in 3D. RESULTS: 14 out of 33 patients were diagnosed with prostate cancer. These results showed a positive correlation between MRI findings and histopathology in 22 out of 33 patients. In MRI lesions marked as highly suspicious, the detection rate was 100%. Evaluating the biopsies from lesions marked as highly and as questionable suspicious together, prostate cancer was detected in 27.95%. In comparison, only 8% of the additional systematic biopsies were positive. Target registration error of the first 554 biopsy cores was 1.9 mm. For adverse effects, one patient experienced urinary retention. Postinterventional hemorrhage or urinary tract infection did not occur. CONCLUSIONS: Perineal stereotactic prostate biopsies guided by the combination of MRI and ultrasound enable effective examination of suspicious MRI lesions. Additionally, each biopsy core taken may be documented accurately for its location in 3D. Thus, MRI data may be validated and different treatment options stratified in depth. At the same time the morbidity of the procedure was minimal.

BD ProEx™C immunostaining in extramammary Paget's disease and perineal melanoma

The differential diagnosis of perineal biopsies can include squamous intraepithelial lesions, extramammary Paget's disease, and melanoma. Less frequently two of these lesions coexist. BD ProEx™C is a recently developed immunoassay that targets expression of two genes shown to be associated with cervical cancer. Immunostaining for ProEx™C has been validated in cervical cytology and positive staining has also been shown to be strongly associated with human papilloma virus (HPV)-induced cervical and anal intraepithelial neoplasia in biopsies. We observed positive staining for ProEx™C in Paget cells in all of 26 cases of Paget's disease irrespective of tissue site (extramammary, mammary) and in melanoma cells in all of 12 cases of primary perineal melanoma with immunostaining in >50% of malignant cells in 73% of Paget disease cases and 43% of perineal melanoma cases. Positive staining was heterogeneous and exclusively nuclear in all cases. In situ hybridization was negative for low-risk and high-risk HPV subtypes in all Paget and melanoma cases that were tested. Currently neither of these lesions is known to be HPV related although according to the literature the possibility of a role for HPV in melanoma is still unsettled. Relevant literature is reviewed.

Oral 10, Childhood mucous membrane pemphigoid: successful control with mycophenolate mofetil monotherapy

An 11-year-old girl was referred to the oral medicine clinic with a history of painless desquamative gingivitis. Histopathology had shown a nonspecific chronic gingivitis. A repeat biopsy with direct immunofluorescence was declined but circulating antibasement membrane antibodies were positive at a titre of 1 : 10. Salt split-skin staining localized to the roof of the blister was consistent with mucous membrane pemphigoid (MMP). Ophthalmological examination was negative. The gingivitis was managed with oral hygiene measures. Six months later she developed dysuria and vulval irritation associated with greenish discharge. Examination under anaesthesia revealed an ulcerated plaque affecting the posterior fourchette and perianal region. Histopathology of a perineal biopsy showed a perivascular lymphocytic infiltrate with epidermal separation from the dermis. Topical clobetasol propionate failed to confer any benefit. Due to its low toxicity compared with other immunosuppressants, mycophenolate mofetil (MMF) was commenced. This resulted in significant control of the MMP. To accelerate healing and bring about complete remission, a course of prednisolone was started at 30 mg daily, tapering to 2 mg on alternate days. Her MMP healed with no residual activity and she has been maintained on MMF 2 g daily. She continues to be monitored by an ophthalmologist. MMP is a rare immunobullous disorder, which affects the skin and mucosal surfaces producing erosions and subsequently scarring. It is relatively rare in children and affects mainly middle-aged and elderly women. A variety of treatments is effective in controlling MMP including dapsone, azathioprine, cyclophosphamide, sulfasalazine and intravenous immunoglobulins. MMF has been reported to be a useful adjunct in MMP. It reversibly inhibits inosine monophosphate dehydrogenase that blocks de novo synthesis of purines, which in turn decreases T- and B-cell activity. The lack of significant myelosuppression, nephrotoxicity or hepatotoxicity makes it a promising treatment for childhood MMP.

Cytomegalovirus neuritis in perineal ulcers.

Although a range of cytomegalovirus (CMV)-induced cutaneous manifestations is described in AIDS patients, skin involvement in immunocompromised patients is rare, and intraneural CMV inclusions or CMV neuritis has not been documented in skin biopsies. Cutaneous biopsies of CMV lesions were collected prospectively for 12 months. The morphology, sites and symptomatology of the individual lesions, associated systemic illnesses, treatment schedules and disease outcome were recorded. A total of nine biopsies were obtained from three females who presented with extensive painful perineal ulceration and disseminated cutaneous ulcers, nodules and plaques. Clinically, herpes simplex virus (HSV) ulceration was diagnosed and treatment with acyclovir was initiated after biopsies from the natal cleft, perineum and neck were obtained. All were superficial and demonstrated HSV infection. Only the natal cleft biopsy demonstrated coexistent CMV inclusions. Suboptimal healing necessitated two further biopsies from each patient, none of which demonstrated HSV inclusions. Three of four deep perineal biopsies demonstrated CMV inclusions within nerves attended by a lymphocytic infiltrate and architectural disturbances. Two deep cutaneous biopsies of the trunk and abdominal wall confirmed CMV in extraneural locations only. One superficial perineal biopsy did not demonstrate any viral inclusion. In documenting CMV neuritis in painful perineal ulcers, the histopathological spectrum of perineal CMV ulcers is expanded, a cutaneous neurotropic characteristic of CMV is presented and a direct role for CMV in the pathogenesis of pain is suggested. CMV latency within perineal nerves is also revisited as another potential site of CMV reactivation in immunocompromised patients, and another potential site for possible venereal transmission of CMV infection. The exclusive presence of HSV in initial superficial biopsies highlights the need for optimally biopsied tissue to confirm the coexistence of CMV infection.

Patterns of care for metastatic carcinoma of the prostate gland: results of the American College of Surgeons' patient care evaluation study.

The annual incidence of prostate cancer more than doubled between 1984 and 1990, increasing from an estimated 76 000-200 000 cases respectively. Part of this increase may have been the result of increased detection. This study utilizes data from an American College of Surgeons Patient Care Evaluation (PCE) study to report on changes in the management of metastatic disease. Approximately 2000 hospitals were invited to submit data on a standard collection form designed by a multidisciplinary committee of specialists. Data were received from 730 hospitals on 14 716 patients with newly diagnosed cancer of the prostate in 1984, and from 1035 hospitals for 23 214 patients in 1990. Between 1984 and 1990 there was a decrease in the percentage of reported patients diagnosed with Stage IV disease, falling from 25.3-21.2%. The number of patients receiving a prostate specific antigen (PSA) test increased from 6.3-74.8% and the proportion of abnormal PSA results increased from 82-92.7%. The proportion of patients diagnosed by transurethral resection of the prostate (TURP) and perineal biopsy decreased, while an increase was noted in the proportion of men diagnosed by transrectal biopsy and transrectal ultrasound (TRUS). Treatment by orchiectomy alone increased from 31.8-40.7% of patients, while the administration of exogenous hormone therapy alone declined from 22.3-14.9% of patients. Two and five-year survival rates for the most common forms of therapy were 56.7% and 22.5% respectively for orchiectomy, 57% and 24.6% respectively for exogenous hormone therapy, and 50.3% and 23.5% respectively for no cancer directed therapy. Following a second course of therapy, the two-year survival rate for patients receiving a subsequent orchiectomy was 36.7 vs 17.8% for those receiving secondary exogenous hormone therapy. The percentage of patients diagnosed with Stage IV disease has decreased while prostate cancer diagnoses are being made more frequently utilizing the PSA test and TRUS biopsies. Hormone treatment remains the most common form of therapy with either orchiectomy or exogenous hormone therapy having higher survival rates than other common treatment modalities.

Long-Term Follow-Up after Open Perineal Cryotherapy in Patients with Locally Confined Prostate Cancer

Appropriate therapies for locally confined adenocarcinoma of the prostate are available-but there is as yet no gold standard of therapy. For that reason, old therapeutic regimens are being revised. One such regimen is cryotherapy. Between 1976 and 1989, 1,250 patients were seen with newly diagnosed prostate cancer. Sixty-six patients of stages T1c (n = 3), T2a (n = 32), T2b (n = 9), T2c (n = 11), T3a (n = 4), T3b (n = 5) and T3c (n = 2) were treated by open perineal cryotherapy. Mean age was 68 years. Three months after surgery, transurethral resection of the prostate and/or perineal biopsy was performed. In 66% of patients with stages T1c-T2b and in 87% of patients with stages T2c-T3c, positive biopsies were obtained. To date, 28 patients have died between 3 and 16 years after cryotherapy, with a mean survival of 7.2 years. The mean follow-up period of survivors (38 patients) is 8.5 years. Complications were: stress-incontinence in 10%, impotence in 10% and temporary rectoperineal fistula in 8%. Cryosurgery is an effective treatment for locally confined prostate cancer. With improvement of the procedure, clinical outcome may also improve.