Biomedical subjects
G L Andriole
Publications and source records attributed to G L Andriole.
Medical therapy for benign prostatic hyperplasia.
Benign prostatic hyperplasia (BPH) is a common clinical entity in elderly men. We review the epidemiology of BPH and the mechanisms by which it causes bladder outlet obstruction. The currently available medical therapies are examined with respect to mechanism of action, effectiveness, side effects, and cost. They are briefly compared with the more traditional treatment options of watchful waiting and transurethral prostatectomy. A logical approach to the treatment of symptomatic BPH is discussed.
Prostate carcinoma.
Over the last several years, the development of prostate-specific antigen (PSA) testing and technical refinements of anatomic radical prostatectomy have revolutionized the care of patients with prostate cancer. Serum PSA testing often allows early diagnosis of organ-confined prostate cancer. Anatomical radical prostatectomy has a high probability of completely eradicating these tumors, with minimal long-term morbidity. Use of PSA testing after therapy confirms the long-term ability of surgery to eradicate early-stage prostate cancer.
Serum prostate-specific antigen: expanding its role as a measure of treatment response in patients with prostate cancer.
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Using PSA to screen for prostate cancer. The Washington University experience.
The evidence is mounting that PSA-based screening for prostate cancer is rational and effective at detecting a high proportion of cancer that is both clinically significant and curable by radical prostatectomy. However, more information is necessary to define the optimal ages at which screening should be performed and to determine the appropriate role of repetitive PSA measurement, PSA density, and PSA slope in serial screening. Formal demonstration of a significant screening-induced reduction of cancer-specific morbidity and mortality is necessary to unambiguously justify screening for prostate cancer. A randomized trial evaluating prostate cancer screening will soon be started under the auspices of the National Cancer Institute. Additionally, refinements in serum PSA testing that consider the variable binding of PSA derived from benign and malignant prostatic tissues to serum proteins may further enhance the performance of PSA testing in the screening setting. For these reasons, PSA-based screening for prostate cancer seems destined to remain an important strategy for minimizing the health consequences of this disease.
Serum PSA after antiandrogen therapy.
Patients who present with advanced prostate cancer and who are treated with primary endocrine therapy have a significantly longer time to progression and a clear survival advantage if their serum PSA concentration normalizes. The prognostic significance of normalization of PSA is independent of other prognostic measures. Normalization of serum PSA at month 3 is the earliest and most highly correlated predictor of response. Most patients (80%-85%) who have disease progression while on hormonal therapy will show a rising PSA 6 to 12 months before other clinical findings become abnormal. A rising PSA in the hormonally treated patient, even if the values are within the "normal" range, signals impending clinical progression. These patients should be considered for second-line hormonal therapies or alternative salvage protocols, as a theoretically favorable window of opportunity may exist when the PSA begins to rise. Patients treated with second-line therapies should also undergo serial PSA measurements; those responding with an 80% to 90% decrease in serum PSA are statistically more likely to enjoy a prolonged response.
The case for prostate cancer screening.
Evidence is mounting indicating that screening for prostate cancer is rational and appropriate. More information is necessary to define the optimal ages at which screening should be performed and to determine the appropriate role of PSA, PSA velocity, and PSA density in serial screening. Formal demonstration of a significant screening-induced reduction in cancer-specific morbidity and mortality is necessary to unambiguously justify screening. A prospective, randomized trial evaluating prostate cancer screening will soon be underway.
The effect of finasteride in men with benign prostatic hyperplasia. The Finasteride Study Group.
BACKGROUND: Benign prostatic hyperplasia is a progressive, androgen-dependent disease resulting in enlargement of the prostate gland and urinary obstruction. Preventing the conversion of testosterone to its tissue-active form, dihydrotestosterone, by inhibiting the enzyme 5 alpha-reductase could decrease the action of androgens in their target tissues; in the prostate the result might be a decrease in prostatic hyperplasia and therefore in symptoms of urinary obstruction. METHODS: In a double-blind study, we evaluated the effect of two doses of finasteride (1 mg and 5 mg) and placebo, each given once daily for 12 months, in 895 men with prostatic hyperplasia. Urinary symptoms, urinary flow, prostatic volume, and serum concentrations of dihydrotestosterone and prostate-specific antigen were determined periodically during the treatment period. RESULTS: As compared with the men in the placebo group, the men treated with 5 mg of finasteride per day had a significant decrease in total urinary-symptom scores (P less than 0.001), an increase of 1.6 ml per second (22 percent, P less than 0.001) in the maximal urinary-flow rate, and a 19 percent decrease in prostatic volume (P less than 0.001). The men treated with 1 mg of finasteride per day did not have a significant decrease in total urinary-symptom scores, but had an increase of 1.4 ml per second (23 percent) in the maximal urinary-flow rate, and an 18 percent decrease in prostatic volume. The men given placebo had no changes in total urinary-symptom scores, an increase of 0.2 ml per second (8 percent) in the maximal urinary-flow rate, and a 3 percent decrease in prostatic volume. The frequency of adverse effects in the three groups was similar, except for a higher incidence of decreased libido, impotence, and ejaculatory disorders in the finasteride-treated groups. CONCLUSIONS: The treatment of benign prostatic hyperplasia with 5 mg of finasteride per day results in a significant decrease in symptoms of obstruction, an increase in urinary flow, and a decrease in prostatic volume, but at a slightly increased risk of sexual dysfunction.
Inguinal mass in a 66-year-old man.
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MR imaging of benign prostatic hypertrophy using a Helmholtz-type surface coil.
MR examinations of the prostate were performed on six healthy volunteers and 18 patients with well-documented symptomatic benign prostatic hypertrophy, using an organ-encompassing Helmholtz-type surface coil at 1.5 T. The healthy volunteers were also imaged with a standard circumferential body coil. The morphologic features and signal intensity characteristics of the prostate and adjacent structures were analyzed in the patient group. Several recognizable patterns of benign prostate hypertrophy were identified including bilaterally symmetrical nodules in the central gland, multiple central gland nodules, and a diffusely heterogeneous central gland without appreciable nodules. The peripheral zone was of moderate to high signal intensity on T2-weighted images, and was diffusely heterogeneous in 78% of patients. The false prostatic capsule, peripheral venous plexus, and seminal vesicles were also characterized. A good correlation was shown between prostatic glandular volume and prostate-specific antigen. Calculated signal-to-noise ratios (S/N) were significantly greater on images acquired with the Helmholtz-type receiver coil than on those acquired with the body coil. We conclude that the hyperplastic prostate gland has a variety of MR appearances, but that recognizable patterns are frequently seen. High resolution imaging with a Helmholtz-type surface coil provides excellent anatomical depiction of the prostate and adjacent structures.
Testicular circulatory isolation: a phase I study.
Antineoplastic agents may damage germinal epithelium. Testicular circulatory isolation (TCI) is a regional drug exclusion technique designed to minimize this. We evaluated the technical and anaesthetic aspects of TCI in 10 patients who underwent bilateral orchiectomy immediately thereafter. A modified aortic clamp was placed trans-scrotally across the left testicular pedicle without pre-medication or anaesthesia and left in place for 1 h, occluding testicular blood flow. Minimal pain and anxiety were reported during the procedure. There were no complications related to TCI in any patient. This study supports the institution of trials of TCI in young men about to receive fertility-threatening chemotherapy.
Re: Predicting radionuclide bone scan findings in patients with newly diagnosed, untreated prostate cancer: prostate specific antigen is superior to all other clinical parameters.
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Testicular tumors: findings with color Doppler US.
A study of 28 patients with surgically proved testicular tumors was performed to determine the appearance at color Doppler ultrasound (US) scanning. There was a general correlation of tumor size and vascularity. Twenty of 21 (95%) tumors larger than 1.6 cm were hypervascular. Six of seven (86%) tumors smaller than 1.6 cm were hypovascular. One small, 1.1-cm-diameter seminoma was hypervascular, and one 2.8-cm-diameter seminoma was hypovascular. The histologic findings of the tumor did not correlate with the vascularity of the lesion as seen at color Doppler US. Resistive indexes ranged from .476 to 1.0 (mean, 0.70). Peak systolic velocities ranged from 8.4 cm/sec to 64.9 cm/sec (mean, 9.8 cm/sec). Venous flow was detected in eight tumors. The gray-scale findings, as well as history and physical examination findings, correctly suggested a neoplasm in all cases. The findings at color Doppler US were prospectively interpreted as indicative of neoplasm in 27 cases and as indicative of inflammation in one case. The authors conclude that color Doppler US scanning has only a limited role in the evaluation of testicular tumors.
Serum prostate-specific antigen: the most useful tumor marker.
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Renal autotransplantation in the management of a ureteroarterial fistula: a case report and review of the literature.
A 57-year-old woman who had been treated with an indwelling ureteral stent for over a year was admitted with massive gross hematuria caused by a fistula between the left ureter and hypogastric artery. Despite intensive radiographic evaluation, the definitive diagnosis was made only at the time of surgical exploration. Because of radiation-induced retroperitoneal fibrosis, midureteral obstruction, and prior pelvic and abdominal surgery, primary ureteral repair was not possible, and renal autotransplantation was performed. This case illustrates the need to consider the diagnosis of ureteroarterial fistula in patients with massive hematuria who have chronic indwelling stents, and the feasibility of autotransplantation when primary ureteral repair is not feasible.
Measurement of prostate-specific antigen in serum as a screening test for prostate cancer.
BACKGROUND: Prostate-specific antigen (PSA) is secreted exclusively by prostatic epithelial cells, and its serum concentration is increased in men with prostatic disease, including cancer. We evaluated its usefulness in the detection and staging of prostate cancer. METHODS: We measured serum PSA concentrations in 1653 healthy men 50 or more years old. Those with PSA values greater than or equal to 4.0 micrograms per liter then underwent rectal examination and prostatic ultrasonography. Ultrasound-directed prostatic needle biopsies were performed in the men with abnormal findings on rectal examination, ultrasonography, or both. The results were compared with those in 300 consecutively studied men 50 or more years old who underwent ultrasound-directed biopsy because of symptoms or abnormal findings on rectal examination. RESULTS: Serum PSA levels ranged from 4.0 to 9.9 micrograms per liter in 6.5 percent of the 1653 men (107). Nineteen of the 85 men in this group (22 percent) who had prostatic biopsies had prostate cancer. Serum PSA levels were 10.0 micrograms per liter or higher in 1.8 percent of the 1653 men (30). Eighteen of the 27 men in this group (67 percent) who had prostatic biopsies had cancer. If rectal examination alone had been used to screen the men who had biopsies, 12 of the 37 cancers (32 percent) would have been missed. If ultrasonography alone had been used to screen these men, 16 of the 37 cancers (43 percent) would have been missed. Serum PSA measurement had the lowest error rate of the tests, and PSA measurement plus rectal examination had the lowest error rate of the two-test combinations. CONCLUSIONS: The combination of measurement of the serum PSA concentration and rectal examination, with ultrasonography performed in patients with abnormal findings, provides a better method of detecting prostate cancer than rectal examination alone.
The ability of systematic transrectal ultrasound guided biopsy to detect prostate cancer in men with the clinical diagnosis of benign prostatic hyperplasia.
Multiple directed and systematic ultrasound guided biopsies of the prostate were performed in 73 men with the clinical diagnosis of benign prostatic hyperplasia (BPH). Seven men (10%) had prostate cancer. Of the 67 patients with benign biopsies 40 underwent subsequent transurethral prostatectomy and 2 (5%) had prostate cancer. Multiple directed and systematic biopsies of the prostate detected 78% of the nonpalpable prostate cancers diagnosed in the study population. Radical prostatectomy was performed in all 9 men with prostate cancer: there were 3 small organ-confined tumors, 5 large organ-confined tumors and 1 stage C tumor with 1 focus of microscopic capsular penetration. Our results suggest that multiple directed and systematic ultrasound guided biopsies are capable of detecting low volume nonpalpable prostate cancer in men with BPH. However, the exact indication for pre-treatment ultrasound guided biopsy of the prostate in men with symptomatic BPH remains unclear. It may be that use of this modality is most appropriate for patients undergoing pharmacological therapy or balloon dilation of BPH rather than for those undergoing transurethral prostatectomy.
Correlation of testicular color Doppler ultrasonography, physical examination and venography in the detection of left varicoceles in men with infertility.
High resolution color Doppler ultrasound is a noninvasive means of simultaneously imaging and evaluating the blood flow to the testes. To define the ability of color Doppler ultrasound to detect clinically evident as well as subclinical varicoceles men referred to our urology division with oligospermia and infertility underwent spermatic vein venography of the left testis if there was physical examination and/or color Doppler ultrasound evidence of a varicocele. The detection of valvular incompetence on venography was considered diagnostic for a varicocele. Of 17 study patients physical examination detected 10 of 14 venographically evident varicoceles (71%), whereas color Doppler ultrasound detected 13 of 14 (93%). Of 5 patients with a normal physical examination but with color Doppler ultrasound evidence of a varicocele 4 had a confirmatory venogram, and 1 of 2 patients with a varicocele on physical examination and a normal Doppler ultrasound had a positive venogram. These data suggest that color Doppler ultrasound of the testis may more appropriately direct further invasive testing and therapy of infertile men than physical examination alone.