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PubMed2004

Synchronous lesions detected by autofluorescence bronchoscopy in patients with high-grade preinvasive lesions and occult invasive squamous cell carcinoma of the proximal airways.

The cancerization field concept implies that lung cancer multicentricity may be a frequent event and primary studies using white-light bronchoscopy (WLB) have reported a high prevalence of multicentricity in patients with roentgenographically occult lung cancer. We have used autofluorescence bronchoscopy (AFB) to reassess the prevalence of synchronous lesions in patients referred for the staging and/or treatment of occult lesions initially detected during WLB. All the patients referred with high-grade preinvasive lesions (severe dysplasia, DYS S and carcinoma in situ, CIS) and occult invasive squamous cell carcinoma (CIV) of the bronchus initially detected during WLB at other centers, underwent AFB. Data were prospectively collected and retrospectively analyzed to assess the prevalence of synchronous occult lesions. From January 1996 to December 2001, 28 patients (26 males, 2 females; mean age: 65 +/- 11) were assessed. After re-evaluation, in two cases, the referred lesions corresponded only to metaplasia and were discarded from analysis. The 26 other patients were referred for 28 lesions (3 DYS S, 19 CIS and 6 CIV; 2 patients were referred with two synchronous lesions). AFB revealed, in these 26 patients, six additional lesions (1 DYS S, 4 CIS and 1 CIV). Multicentricity in this group, initially estimated to amount to 7% with WLB alone, raised to 23% by using AFB. The high prevalence of synchronous lesions in this series of patients with occult DYS S, CIS and occult CIV suggests that AFB may be a useful adjunct in the pretreatment evaluation.

Aged↗
PubMed2003

Positron emission tomography for detecting occult hepatocellular carcinoma in hepatitis C cirrhotics awaiting for liver transplantation.

Patients with hepatitis C cirrhosis may sometimes have persistently elevated alpha feto protein (AFP) despite a lack of evidence for disease by ultrasound or computed tomography (CT). While this pattern may represent a benign manifestation of hepatitis C cirrhosis (HCC), it raises concern for the possibility of an occult hepatocellular carcinoma. It has previously been shown that positron emission tomography (PET scan) may detect occult cholangiocarcinoma in high-risk patients with primary sclerosing cholangitis. We hypothesized that PET scanning might similarly serve for occult HCC in hepatitis C cirrhotics. PET scanning was performed on eight hepatitis C cirrhotics who were on the liver transplantation list and displayed persistently elevated AFP (>100 ng/mL) but no detectable lesions on abdominal CT scan. The results of PET detection of occult HCC were compared to those obtained with lipiodol-enhanced CT scanning and with histologic examination of the live explant. Explant histology or prolonged clinical follow-up showed two subjects to have conclusive evidence of HCC; the remainder, no evidence of malignancy. Although PET imaging did not reveal abnormal lesions in any subject; lipiodol-enhanced CT scans revealed abnormal lipiodol retention in both subjects with HCC. These preliminary findings suggest that PET has no role in detecting occult HCC in high-risk patients. Additionally, these data suggest that some hepatitis C cirrhotics with persistently elevated AFP but no detectable lesions by conventional CT scan may show occult HCC using lipiodol-enhanced CT scans.

Aged↗
PubMed1998

Occult giant cell arteritis: ocular manifestations.

PURPOSE: To report the incidence, visual symptoms, and ocular signs of occult giant cell arteritis in patients who initially presented with visual symptoms and ocular signs of giant cell arteritis. Occult giant cell arteritis was defined as ocular involvement by giant cell arteritis without any systemic symptoms and signs of giant cell arteritis. METHODS: In a prospective study from 1973 to 1995, we investigated 85 patients who had ocular involvement caused by giant cell arteritis and whose diagnosis of giant cell arteritis was confirmed on temporal artery biopsy. At the initial visit, patients were questioned specifically on systemic and ocular symptoms and signs of giant cell arteritis at or before the onset of visual disturbance. Erythrocyte sedimentation rate (Westergren) and C-reactive protein level were evaluated before the start of systemic corticosteroid therapy. RESULTS: Eighteen (21.2%) of 85 patients had occult giant cell arteritis. There was no significant difference in age and sex distribution between patients with and without systemic symptoms of giant cell arteritis. Although both groups of patients had abnormal erythrocyte sedimentation rate and C-reactive protein level, there was a significant difference in erythrocyte sedimentation rate (P < .0001) and C-reactive protein level (P=.0133), these being relatively lower in patients with occult giant cell arteritis. The ocular symptoms in the 18 patients with occult giant cell arteritis were visual loss of varying severity in 18 (100%), amaurosis fugax in six (33.3%), diplopia in two (11.1%), and eye pain in one (5.6%). Ocular ischemic lesions consisted of anterior ischemic optic neuropathy in 17 (94.4%), central retinal artery occlusion in two (11.1%), and cilioretinal artery occlusion in two (of 11 patients with satisfactory fluorescein angiography [18.2%]). The ocular symptoms and ischemic lesions were seen in a variety of combinations. CONCLUSIONS: Because occult giant cell arteritis is a potential cause of blindness, its early diagnosis is the key to preventing blindness; it is important to recognize that 21.2% of patients with giant cell arteritis and visual loss do not have any systemic symptoms of giant cell arteritis. Thus, in persons older than 55 years, amaurosis fugax or visual loss, development of an acute ocular ischemic lesion (particularly arteritic anterior ischemic optic neuropathy), and abnormal C-reactive protein level, with or without elevated erythrocyte sedimentation rate and systemic symptoms, should raise a high index of suspicion for giant cell arteritis.

Aged↗
PubMed1989

Temperature response to acetaminophen and risk of occult bacteremia: a case-control study.

A case-control study of 34 children with occult bacteremia was conducted to test the hypothesis that nonresponse to acetaminophen (decrease less than or equal to 0.8 degrees C) is a risk factor for occult bacteremia. Febrile children visiting the emergency center from May 1986 to October 1987 were monitored for occult bacteremia. Inclusion criteria were age 2 months to 6 years, temperature greater than or equal to 38.9 degrees C, and having a blood culture. Exclusion criteria were serious acute or chronic illness, sponging for fever reduction, current therapy with antibiotics or steroids, and admission to the hospital. Records of 3892 febrile children were reviewed. Of these, 2101 (54%) had a blood culture and 1028 (26%) were eligible. All patients (positive blood culture) were matched with two control subjects (negative blood culture). Patients and control subjects had similar age, gender, ethnicity, height of initial temperature, time to second temperature, and dose of acetaminophen. The estimated risk of occult bacteremia for nonresponders was 9.2 (95% confidence interval 2.7, 32.0). We conclude that children who do not respond to acetaminophen by at least a 0.8 degrees C decrease in temperature have an increased risk of occult bacteremia. However, achieving a response to acetaminophen does not eliminate the possibility that the child has occult bacteremia.

Acetaminophen↗
PubMed2003

Transpupillary thermotherapy of predominantly occult choroidal neovascularization in age-related macular degeneration with 12 months follow-up.

PURPOSE: To perform a phase I/II safety and efficacy study in order to assess the outcome following transpupillary thermotherapy (TTT) for occult choroidal neovascularization (CNV) with no or minimally classic CNV in age-related macular degeneration. METHODS: The study comprised 113 referred patients (79 females, 34 males) aged 59-89 years (mean 77.7 years) with predominantly occult CNV. There were 49 cases of occult with no classic CNV and 64 of occult with minimally classic CNV. According to their greatest linear dimension, lesions were classified as being < 3.0 mm or > 3.0 mm. Transpupillary thermotherapy was delivered with a diode laser, emission at 810 nm, duration 60 seconds, laser power 500-800 mW. Clinical examination, ETDRS logMAR visual acuity and fluorescein angiography were carried out at baseline, and at 3, 6 and 12 months in all cases. RESULTS: The average baseline visual acuity was 0.20 (50.6 letters). Following TTT, it was 0.12 (42.0 letters) at 6 months and 0.12 (38.0 letters) at 12 months. Visual acuity improved in 9/113 eyes (8.0%), remained unchanged in 46 (40.7%) eyes, and deteriorated in 58 (51.3%) eyes. There was no significant difference in the proportion of eyes that had lost at least 15 letters at 12 months in the subgroup of occult with no classic CNV (18/49; 36.7%) versus those with minimally classic lesions < 3.0 mm (15/39; 38.5%). However, 13/25 (52.0%) of cases with minimally classic lesions > 3.0 mm had lost at least 15 letters at 12 months (p = 0.31). The most common complications in the 46 eyes that suffered visual loss comprised subretinal progressive fibrosis (18 eyes) and atrophy of the retinal pigment epithelium (13 eyes). CONCLUSIONS: This study shows that TTT generally prevents moderate and severe visual loss at 12 months follow-up in occult CNV with no classic CNV. Eyes with minimally classic lesions with a greatest linear dimension of < 3.0 mm also show the same positive outcome. These results compare favourably with published data on the natural course of the disease. However, minimally classic lesions of > 3.0 mm responded poorly in this treatment setting.

Aged↗
PubMed2002

Occult axillary lymph node metastases are of no prognostic significance in breast cancer.

The significance of occult metastases in axillary lymph nodes in patients with carcinoma of the breast is controversial. Additional sections were cut from the axillary lymph nodes of 477 women with invasive carcinoma of the breast, in whom no metastases were seen on initial assessment of haematoxylin and eosin stained sections of the nodes. One section was stained with haematoxylin and eosin, and one using immunohistochemistry with two anti-epithelial antibodies (CAM5.2 and HMFG2). Occult metastases were found in 60 patients (13%). The median follow-up was 18.9 years with 153 breast cancer related deaths. There was no difference in survival between those with and those without occult metastases. Multivariate analysis, however, showed that survival was related to tumour size and histological grade. This node-negative group was compared with a second group of 202 patients who had one involved axillary node found on initial assessment of the haematoxylin and eosin sections; survival was worse in the patients in whom a nodal metastasis was found at the time of surgery. Survival was not related to the size of nodal metastases in the occult metastases and single node positive groups. Some previous studies have found a worse prognosis associated with occult metastases on univariate analysis, but the evidence that it is an independent prognostic factor on multivariate analysis is weak. We believe that the current evidence does not support the routine use of serial sections or immunohistochemistry for the detection of occult metastases in the management of lymph node negative patients, but that the traditional factors of histological grade and tumour size are useful.

Adult↗
PubMed1999

Mapping of occult melanoma micrometastases in the inguinal lymph node basin by immunohistochemistry and RT-PCR.

To examine the distribution of occult micrometastases that could be potential sources of recurrence, complete maps of microscopic and submicroscopic metastases in entire inguinal lymph node basins were generated in 13 melanoma patients who had undergone elective or therapeutic lymphadenectomy. Occult micrometastases were analysed immunohistochemically for the pigment cell-specific antigen HMB-45 in all 155 nodes and using a reverse transcriptase-polymerase chain reaction (RT-PCR) assay to detect tyrosinase mRNA in 35 nodes. Five patients were determined to be node-negative by routine histopathology; three of these subjects were also negative by RT-PCR and/or immunohistochemistry. However, the remaining two patients had occult metastases, which were confined to a possibly sentinel node in one and were detected in multiple nodes in the other. Eight patients had histological evidence of lymph node metastasis. Three of these patients had no additional detectable submicroscopic disease, and one had occult metastasis in one node adjacent to the histologically positive node. In contrast, the other four patients had occult micrometastases in multiple non-sentinel, higher level nodes. The two patients who relapsed belonged to this group. The results show considerable variation in the distribution pattern of occult metastases in the regional lymph nodes, and have significant implications for the role of regional lymph node dissection, including sentinel node mapping with selective lymphadenectomy, in the management of melanoma patients.

Adult↗
PubMed2003

Occult diaphragmatic injuries caused by stab wounds.

BACKGROUND: Missed diaphragmatic perforation caused by penetrating trauma can lead to subsequent strangulation of a hollow viscus, which has prompted the use of invasive diagnostic procedures to exclude occult diaphragmatic injuries in asymptomatic, high-risk patients. The objective of this study was to determine the incidence of occult diaphragmatic injuries caused by stab wounds of the lower chest and upper abdomen, and to examine the natural history and consequences of missed diaphragmatic injuries. METHODS: On the basis of patient data from two previous randomized studies from our institution, a retrospective analysis was performed on 97 patients treated for anterior stab wounds located between the nipple line, the umbilical level, and the posterior axillary lines not having indications for immediate surgical exploration. The patients were divided into two groups on the basis of their initial randomized management (open or laparoscopic exploration vs. expectant observation). RESULTS: In the exploration group (n = 47), four diaphragmatic injuries (9%) were detected (three left-sided and one right-sided). Excluding patients with associated injuries requiring surgical repair, the incidence of occult diaphragmatic injuries was 3 of 43 (7%). In the observation group (n = 50), there were two patients (4%) with delayed presentation of missed left-sided diaphragmatic injury 2 and 23 months later, respectively. Both injuries resulted from stab wounds of the left flank and presented with herniation of the stomach or small bowel and colon. The overall incidence of occult diaphragmatic injuries in left-sided thoracoabdominal stab wounds was 4 of 24 (17%), and was much lower after stab wounds of left epigastrium (0%), right lower chest (0%), and right epigastrium (4%). CONCLUSION: In asymptomatic patients with anterior or flank stab wounds of the lower chest or upper abdominal area, the risk of an occult diaphragmatic injury is approximately 7% which, if undetected, is associated with a high risk of subsequent hollow viscus herniation. Exclusion of an occult diaphragmatic injury with invasive diagnostic methods, such as laparoscopy or thoracoscopy, should be considered at least in left-sided stab wounds of the lower chest.

Adult↗
PubMed2002

Clinical significance of occult micrometastases in axillary lymph nodes in "node-negative" breast cancer patients.

The most important subgroup of breast cancer patients for whom reliable prognostic indicators are needed is women without axillary lymph node metastases. We evaluated the clinical significance of occult micrometastases in axillary lymph nodes in 148 consecutive "node-negative" breast cancer patients. The median age of the patients at surgery was 52 years and the median follow-up period after surgery was 98.5 months. Occult micrometastases were detected in 21 of 148 patients (14.2%) by means of immunohistochemical analysis using AE1 / 3 antibody and a single unstained section after routine histopathological examination. Log-rank tests indicated that the 7-year disease-free survival (DFS) and overall survival (OS) rates by Kaplan-Meier methods were significantly better in patients without occult micrometastases than in patients with occult micrometastases [DFS, 93% versus 71% (P = 0.0009); OS, 96% versus 76% (P = 0.0001)]. According to Cox's multivariate analysis, the presence of occult micrometastases had the most significant effect on DFS (P = 0.0053) and OS (P = 0.0035). These findings suggest that the presence of occult micrometastases is an independent and significant predictor of clinical outcome, and that their immunohistochemical detection after routine histopathological examination is useful for selecting the "node-negative" breast cancer patient subgroup at high risk for relapse and death.

Adult↗
PubMed2006

Effect of anti-viral therapy for occult hepatitis C virus infection.

BACKGROUND: Occult hepatitis C virus infection is defined by the presence of hepatitis C virus-RNA in liver but with undetectable anti-hepatitis C virus and serum viral RNA. AIM: To study the response to anti-viral therapy in occult hepatitis C virus infection to assess the pathogenic effect of occult hepatitis C virus. METHODS: Ten patients with occult hepatitis C virus infection were treated with pegylated-interferon plus ribavirin for 24 weeks and were followed-up 24 weeks after therapy. All patients had abnormal alanine aminotransferase, hepatitis C virus-RNA positive in peripheral blood mononuclear cells and liver necroinflammation. RESULTS: At the end of treatment and follow-up, the percentage of patients with normal alanine aminotransferase was 80% (95% CI: 48-96%) and 60% (95% CI: 31-84%) respectively, and hepatitis C virus-RNA in peripheral blood mononuclear cells was negative in 80% (95% CI: 48-96%) and 70% (95% CI: 40-90%) cases. At the end of follow-up sustained response was observed in 30% (95% CI: 11-61%) of cases. Five patients underwent a second liver biopsy. In all cases, liver hepatitis C virus-RNA persisted, although hepatitis C virus-RNA load was significantly lower (3.2 x 10(4) +/- 5.1 x 10(4) copies/microg RNA) than in the basal biopsy (2.4 x 10(5) +/- 3.8 x 10(5) copies/microg RNA); (P = 0.043). Necroinflammation and fibrosis decreased in three cases. CONCLUSION: The biochemical, virological and histological response to therapy achieved in patients with occult hepatitis C virus infection demonstrates the pathologic effects of occult hepatitis C virus.

Adult↗
PubMed2004

Occult hepatitis B viral DNA in liver carcinomas from a region with a low prevalence of chronic hepatitis B infection.

Occult hepatitis B is defined by the presence of hepatitis B viral (HBV) DNA in the serum or liver in persons lacking hepatitis B surface antigen (HBsAg) in the serum. A high prevalence of occult HBV has been reported in hepatocellular carcinoma (HCC) from Asia, but little information is available on the prevalence of occult HBV in HCC from regions with a low prevalence of typical chronic hepatitis B infection. In a retrospective study, 19 cases of primary liver cancer were investigated for the presence of occult HBV DNA by amplification of the surface, core, and X gene. In addition, HBV copy numbers were quantitated by real time polymerase chain reaction, genotyped, and samples tested for covalently closed circular HBV DNA, which is a marker of active viral replication. Occult HBV was found in three of 19 cases (16%). Genotyping was successful in two cases, both of which were genotype A. HBV DNA copy numbers were low, all less than 10 copies/microg liver DNA. No closed circular HBV DNA was detected. Thus, in this study occult HBV was of genotype A and was found in a low percentage of cases of HCC and was associated with low tissue HBV DNA copy numbers and no detectable evidence for viral replication.

Adult↗
PubMed2006

A prospective evaluation of occult disorders in obstructed defecation using the 'iceberg diagram'.

OBJECTIVE: Surgical treatment of constipation and obstructed defecation (OD) carries frequent recurrences, as OD is an 'iceberg syndrome' characterized by 'underwater rocks' or occult diseases which may affect the outcome of surgery. The aim of this study was to evaluate occult disorders in order to alert the clinician of these and minimize failures. METHOD: One hundred consecutive constipated patients with OD symptoms, 81 female patients, median age 52 years, underwent perineal examination, proctoscopy, anorectal manometry, and anal/vaginal ultrasound. Anorectal physiology and imaging tests were also carried out when indicated, as well as psychological and urogynaecological consultation. Symptoms were graded using a modified 1-20 constipation score. Both evident (e.g. rectocele) and occult (e.g. anismus) diseases were prospectively evaluated using a novel 'iceberg diagram'. The type of treatment, whether conservative or surgical, was also recorded. RESULTS: Fifty-four (54%) patients had both mucosal prolapse and rectocele. All patients had at least two occult OD-related diseases, 66 patients had at least three: anxiety-depression, anismus and rectal hyposensation were the most frequent (66%, 44% and 33% respectively). The median constipation score was 11 (range 2-20), the median number of 'occult disorders' was 5 (range 2-8). Conservative treatment was carried out in most patients. Surgery was carried out in 14 (14%) patients. CONCLUSION: The novel 'iceberg diagram' allowed the adequate evaluation of OD-related occult diseases and better selection of patients for treatment. Most were managed conservatively, and only a minority were treated by surgery.

Adult↗
PubMed2006

Occult anal sphincter injuries--myth or reality?

OBJECTIVES: To establish the true prevalence of clinically recognisable and occult obstetric anal sphincter injuries (OASIS). DESIGN: Prospective interventional study. SETTING: Busy district general hospital. SAMPLE: Two hundred and fifty-four women having their first vaginal delivery over a 12-month period were invited. Two hundred and forty-one (95%) participated and 208 (86%) attended follow up. METHODS: Women had a clinical examination at delivery by the accoucheur and repeated by an experienced research fellow immediately after delivery. All identified OASIS were verified and repaired by the duty specialist registrar or consultant. Endoanal ultrasound was performed immediately postpartum prior to suturing and repeated seven weeks later. MAIN OUTCOME MEASURES: Prevalence of recognised and occult anal sphincter injuries. RESULTS: Fifty-nine (24.5%) women sustained OASIS. The prevalence of OASIS increased significantly from 11% to 24.5% when women were re-examined. Of these, 30 occurred in deliveries by midwives who missed 26 (87%) and 29 following deliveries by doctors who missed 8 (28%) injuries. All clinically apparent OASIS were also identified on endoanal ultrasound. In addition, three (1.2%) women had an occult anal sphincter injury. Two of these occult sphincter injuries were isolated to the internal anal sphincter (IAS) and would not usually be clinically detectable. CONCLUSIONS: OASIS occur more frequently than previously reported. Many remain undiagnosed and are subsequently classified as occult when identified on anal endosonography. Genuine occult injuries are rare. Training in perineal anatomy and recognition of OASIS needs to be enhanced in order to increase detection of OASIS and minimise the risk of consequent anal incontinence.

Anal Canal↗
PubMed1994

Effect of Storage Time and Temperature on Fecal Leukocytes and Occult Blood in the Evaluation of Travelers' Diarrhea.

Both the presence of fecal leukocytes and occult blood in stool specimens of travelers with diarrhea have been used as indicators of colonic inflammation due to bacterial infection. This study was conducted to determine if storage temperature of stool specimens can affect the detection of leukocytes and occult blood. Sixteen specimens positive for occult blood and 23 specimens positive for leukocytes were divided into two aliquots. Each aliquot was held at 4 degreesC or 25 degreesC and reexamined daily for fecal leukocytes or occult blood. Four percent of the positive leukocytes specimens and 56% of the occult blood positive specimens were still positive on the fifth day when they were held at 4 degreesC. When the samples were held at 25 degreesC, leukocytes could not be detected after 3 days, but 19% were positive for occult blood on the fifth day. The results indicate that storage temperature of stool specimens was associated with a difference in detection rate.

Journal Article↗
PubMed1992

Occult fracture patterns of the knee associated with anterior cruciate ligament tears: assessment with MR imaging.

One hundred consecutive magnetic resonance (MR) images of the knee in patients with acute complete anterior cruciate ligament (ACL) tears were reviewed to evaluate the prevalence and patterns of associated occult fractures. Eighty-nine occult fractures were identified in 56 knees. All occult fractures were in the posterior aspect of the lateral tibial plateau. Of these, occult fractures were isolated in 24 cases (43%) and were in combination with fractures in the middle aspect of the lateral femoral condyle in 26 (46%), with fractures in the posterior aspect of the medial tibial plateau in four (7%), and with fractures involving all three areas in one (2%). Disruption of the ACL under valgus stress leads to anterior translation of the tibia and relative external rotation of the femur. This allows impaction of the posterior portion of the lateral tibial plateau against the middle of the lateral femoral condyle and accounts for the unique pattern of occult fractures associated with ACL tears. An occult fracture of the posterior lateral tibial plateau with or without an associated fracture in the lateral femoral condyle ("kissing contusion") is a relatively frequent finding in acute ACL tears and, when present, is highly suggestive of such an associated tear.

Adolescent↗
PubMed2003

Predictors of occult metastasis in clinical stage I nonseminoma: a systematic review.

PURPOSE: Patients with clinical stage I nonseminomatous testicular germ cell tumor should ideally receive adjuvant therapy only when they are at high risk for occult metastasis. We aimed to quantify the importance of predictors for occult metastasis by performing a systematic review of the relevant literature. In addition, we reviewed published multivariable models and risk-adapted treatment policies. PATIENTS AND METHODS: We identified 23 publications between 1979 and 2001, reporting a total of 2,587 patients. Twenty-nine percent of the patients (759 of 2,587 patients) had occult metastases, which was diagnosed either at retroperitoneal lymph node dissection (n = 193) or during follow-up (n = 566). Odds ratios (OR) were pooled using meta-analysis techniques. RESULTS: The presence of vascular invasion of the primary tumor cells had the strongest effect (OR, 5.2; 95% CI, 4.0 to 6.8). Immunohistochemical staining of the primary tumor cells with the MIB-1 monoclonal antibody showing proliferative activity was a promising predictor (OR, 4.7; 95% CI, 2.0 to 11). Intermediate effects were found for embryonal carcinoma in the primary tumor (OR, 2.9; 95% CI, 2.0 to 4.4) and a high pathologic stage of the tumor (OR, 2.6; 95% CI, 1.8 to 3.8). Size of the primary tumor and age of the patient had weaker though also statistically significant associations with occult metastasis. Until now, multivariable models often included vascular invasion and embryonal carcinoma with one or two weaker predictors. None of the published risk-adapted treatment policies included MIB-1 staining. CONCLUSION: Several strong predictors for occult metastasis were identified. A risk-adapted treatment policy should be developed that incorporates all relevant predictors so that adjuvant therapy is targeted better to those with occult metastases.

Adult↗
PubMed2006

Detection of occult lymph node metastases in locally advanced node-negative prostate cancer.

PURPOSE: The purpose of this study was to determine the incidence and clinical significance of occult metastases in the lymph nodes of patients with prostate cancer originally considered node negative by routine histologic evaluation. METHODS: Two hundred seventy four patients with pT3 prostate carcinoma treated by radical prostatectomy and bilateral lymph node dissection were included in this study. One hundred eighty patients were staged node negative (N0), while 94 patients were lymph node positive (N+), based on routine histologic evaluation. All lymph nodes from the 180 N0 patients were evaluated for occult metastases by immunohistochemistry using antibodies to cytokeratins and, if positive, prostate-specific antigen. Recurrence and overall survival were compared among patients with occult tumor cells (OLN+), with patients whose lymph nodes remained negative (OLN-), and with the 94 N+ patients. RESULTS: A total of 3,914 lymph nodes were evaluated from 180 N0 patients (average, 21.7 lymph nodes per patient). Occult tumor cells were found in 24 of 180 patients (13.3%). The presence of OLN+ was significantly associated with increased recurrence and decreased survival compared with OLN- patients (P < .001 and P = .019, respectively; relative risk of recurrence, 2.27; relative risk of death 2.07, respectively). The presence of occult lymph node metastases was an independent predictor of recurrence and death in a multivariable analysis. The outcome for patients with OLN+ disease was similar to that for patients with N+ disease. CONCLUSION: The detection of occult lymph node metastases in patients with pT3N0 prostate cancer identifies those with significantly increased risk of prostate cancer recurrence and death.

Aged↗
PubMed2003

Occult Cushing's syndrome in type-2 diabetes.

Subclinical Cushing's syndrome (SCS) caused by adrenal incidentalomas is frequently associated with overweight and insulin resistance. Metabolic syndrome X may therefore be a clue to the presence of CS. However, the incidence of CS in this situation remains unknown. We have conducted a prospective study to evaluate the prevalence of occult CS in overweight, type-2 diabetic patients devoided of specific clinical symptoms of CS. Two hundred overweight, type-2 diabetic patients, consecutively referred for poor metabolic control (HbA(1C) > 8%), were studied as inpatients. A first screening step was performed with the 1-mg overnight dexamethasone suppression test (DST) using a revised criterion for cortisol suppression (60 nmol/liter) to maximize the sensitivity of the procedure. A second confirmatory step of biochemical investigations (midnight plasma cortisol concentration, plasma cortisol circadian rhythm, morning plasma ACTH concentration, 24-h urinary free cortisol, and 4-mg i.v. DST) was performed in patients with impaired 1-mg DST. A third step of imaging studies was performed according to the results of second-step investigations. Fifty-two patients had impaired 1-mg DST. Among these, 47 were further evaluated. Thirty were considered as false positives of the 1-mg DST, whereas 17 displayed at least one additional biological abnormality of the hypothalamic-pituitary-adrenal axis. Definitive occult CS was identified in four patients (2% of the whole series) with Cushing's disease (n = 3) and surgically proven adrenal adenoma (n = 1). Definitive diagnosis remains to be established in seven additional patients (3.5%) with mild occult CS associated with unsuppressed plasma ACTH concentrations and a unilateral adrenal tumor of 10-29 mm in size showing prevalent uptake at radiocholesterol scintigraphy. In conclusion, a relatively high prevalence of occult CS was found in our study. Further studies are needed to evaluate the impact of the cure of occult CS on obesity and diabetes mellitus in these patients. Such studies might provide a rationale for systematic screening of occult CS in this population.

Aged↗