- Email: [email protected]
Epididymitis and The Acquired Immunodeficiency Syndrome
145
LETTERS TO THE EDITOR in patients more than 40 years old, in black subjects and in individuals with a long-standing testicular mass.' Testicular ultrasound has not proved to be reliable. The accuracy of frozen section examination is better than 95 per cent, although a false negative diagnosis can have serious consequences. Unfortunately, the role of nuclear scanning in the preoperative evaluation of testicular tumors had not been investigated previously. While cystic lesions, such as epidermoid cysts, may appear as "cold" areas, would other types of benign lesions, such as granulomatous orchitis, appear avascular as well? How would cystic malignancies, such as cystic teratomas or cystadenocarcinomas, appear? 2 The sensitivity and specificity of high resolution nuclear scintigraphy in the diagnosis of testicular masses deserve well controlled, prospective investigation. 1. Haas, G. P., Sandler, M. L., Ohorodnik, J. M. and Farah, R. N.:
Benign testicular tumors: is pre-orchiectomy diagnosis possible? J. Urol., part 2, 137: 379A, abstract 1104, 1987. . 2. Haas, G. P., Ohorodnik, J. M. and Farah, R. N.: Cystadenocarc1noma of the rete testis. J. Urol., 137: 1232, 1987.
EPIDIDYMITIS AND THE ACQUIRED IMMUNODEFICIENCY SYNDROME
To the Editor. Epididymitis in immunocompromised patients with the acquired immunodeficiency syndrome (AIDS) can be severe with unusual organisms as the etiological agents. In certain circumstances epididymitis may even be the presenting complaint in patients with AIDS. Recently, we evaluated 3 men with signs and symptoms of epididymitis, who upon further examination were found to have AIDS. Two patients presented with high fever and evidence of systemic sepsis, including lethargy and confusion. Both had a large, tender scrotal mass with no obvious abscess formation, which required extended hospitalization and intravenous antibiotics. The third patient complained of testicular and epididymal tenderness that resolved after oral antibiotic therapy. All 3 patients had oral candidiasis and 1 had Cryptosporidiuminduced diarrhea. Two men had been evaluated previously for unexplained adenopathy but the results were negative. All 3 patients had pyuria but negative urine and blood cultures. Social histories placed each man in a high risk group for AIDS. In retrospect, the unusually severe presentation in conjunction with atypical infections in 2 of these cases indicated systemic immunocompromise. Although immunocompromised AIDS patients classically suffer from regional and systemic infections with organisms that proliferate because of severe T cell and associated B cell abnormalities, 3 epididymitis is not routinely considered as a common infection in this group. However, at least 1 high risk group, homosexuals, is prone to lower urinary tract infections that may be exacerbated by the immunodeficiency of AIDS. Reports of atypical organisms causing epididymitis in immunocompromised hosts 1· 2 may explain the slow resolution of symptoms in a least 1 patient treated with intravenous ampicillin and gentamicin. When acute epididymitis is accompanied by a symptom complex suggestive of AIDS, aggressive cultures for virus, fungus and atypical organisms, as well as possible transscrotal aspiration or open biopsy, may be necessary. In retrospect, the circumstances in these 3 cases demanded a more aggressive microbiological evaluation. AIDS patients may present with subtle complaints of weight loss, fatigue or infectious disease, such as pneumonia. Therefore, a high degree of suspicion is needed for the ultimate diagnosis. Although all patients who present with acute scrotal pain and fever do not necessarily have AIDS, further investigation would be warranted if other signs and symptoms were suggestive or the presentation was unusually severe. Respectfully, Daniel B. Rukstalis and Gary P. Kearney Brigham & Women's Hospital 75 Francis Street Boston, Massachusetts 02115 and William De Wolf Beth Israel Hospital 330 Brookline Avenue Boston, Massachusetts 02215
1. Wheeler, J. S., Jr., Culkin, D. J., O'Connell, J. and Winters, G.:
Nocardia epididymo-orchitis in an immunosuppressed patient. J. Urol., 136: 1314, 1986. 2. Randazzo, R. F., Hulette, C. M., Gottlieb, M. S. and Rajfer, J.: Cytomegaloviral epididymitis in a patient with the acquired immune deficiency syndrome. J. Urol., 136: 1095, 1986. 3. Bowen, D. L., Lane, H. C. and Fauci, A. S.: Immunopathogenesis of the acquired immunodeficiency syndrome. Ann. Intern. Med., 103: 704, 1985.
RE: PROGNOSIS OF UNTREATED STAGE Al PROSTATIC CARCINOMA: A STUDY OF 94 CASES WITH EXTENDED FOLLOWUP
J. I. Epstein, G. Paull, J.C. Eggleston and P. C. Walsh J. Urol., 136: 837-839, 1986 To the Editor. The authors subscribe to the criteria that less than 5 per cent of neoplasm in a prostatic specimen classifies the lesion as stage Al. As they note more stringent criteria classify stage Al disease as 3 or less foci of neoplasm in the total pathological specimen. Two particular problems come to mind. Five per cent of a 50 gm. gland (2.5 gm.) is considerably different than 5 per cent of a 10 gm. gland (0.5 gm.) in terms of pure numbers of neoplastic cells, that is 2.7 billion versus 537 million, not to mention the enormous number of cells in an 80 gm. enucleated specimen (4 gm. equals 4.3 X 109 neoplastic cells). None of the cases had a thorough repeat biopsy of the posterior aspect of the prostatic fossa (3 to 9 o'clock position) to determine if they were staged accurately as AL Any residual neoplasm would indicate that the disease was stage A2. A cubic centimeter of prostatic adenocarcinoma contains approximately 1 billion cells and represents 30 cell doublings. Such a mass would have ample opportunity to produce a "metastatic variant" cell that could implant at a distant site. In comparison 3 or less foci of disease likely represent at most thousands of cells, assuming a focus is defined as an area no larger than 100 to 200 µ. Since each prostatic cancer cell is about 10 µ. in size, the area of such a focus in 3 dimensions would contain between 1,000 and 8,000 cells. These small numbers of neoplastic cells have not had the opportunity to undergo the necessary cell doublings required to produce a metastatic variant cell. Morphometric studies by Dr. Fuad Freiha at Stanford have substantiated that tumor volume is related directly to capsular invasion, seminal vesical invasion and lymph node metastasis. Since 7 of 8 patients with progression had less than 3 foci (size ?) of neoplasm in the pathological specimen, I suspect that the critical volume, even assuming the possibility of residual disease, necessary to produce a metastatic variant cell probably did not exist at the time of initial diagnosis. As a consequence the authors' data also may be interpreted in an alternate manner: the patients referred to in this study with disease progression actually had stage A2 (residual) disease or sufficient time had elapsed during the followup period for the development de novo of an additional prostatic neoplasm. In conclusion, I suggest that more rather than less rigorous criteria be applied for stage A prostatic adenocarcinoma. Respectfully, Richard H. Bard Department of Urology Montefiore Medical Center-Albert Einstein College of Medicine 111 East 210th Street Bronx, New York 10467
Reply by Authors. Recently, we demonstrated at 4 and 8-year followup after diagnosis of stage A carcinoma that the percentage of the specimen involved by tumor was a better predictor of progression than the actual tumor volume resected. 1 As to the question of repeat biopsy we agree with Doctor Bard that since 7 of the 8 patients with progression had such small foci of tumor at initial resection, these cases were not likely to be examples of undersampling but rather they represented progression of minimal residual tumor during a long period. A recent evaluation of our radical prostatectomies done for stage Al carcinoma demonstrated that 86 per cent of the prostates contained residual tumor, which owing to its peripheral and/or apical distribution would not necessarily have been upstaged by repeat transurethral resection. 2
LETTERS TO THE EDITOR in patients more than 40 years old, in black subjects and in individuals with a long-standing testicular mass.' Testicular ultrasound has not proved to be reliable. The accuracy of frozen section examination is better than 95 per cent, although a false negative diagnosis can have serious consequences. Unfortunately, the role of nuclear scanning in the preoperative evaluation of testicular tumors had not been investigated previously. While cystic lesions, such as epidermoid cysts, may appear as "cold" areas, would other types of benign lesions, such as granulomatous orchitis, appear avascular as well? How would cystic malignancies, such as cystic teratomas or cystadenocarcinomas, appear? 2 The sensitivity and specificity of high resolution nuclear scintigraphy in the diagnosis of testicular masses deserve well controlled, prospective investigation. 1. Haas, G. P., Sandler, M. L., Ohorodnik, J. M. and Farah, R. N.:
Benign testicular tumors: is pre-orchiectomy diagnosis possible? J. Urol., part 2, 137: 379A, abstract 1104, 1987. . 2. Haas, G. P., Ohorodnik, J. M. and Farah, R. N.: Cystadenocarc1noma of the rete testis. J. Urol., 137: 1232, 1987.
EPIDIDYMITIS AND THE ACQUIRED IMMUNODEFICIENCY SYNDROME
To the Editor. Epididymitis in immunocompromised patients with the acquired immunodeficiency syndrome (AIDS) can be severe with unusual organisms as the etiological agents. In certain circumstances epididymitis may even be the presenting complaint in patients with AIDS. Recently, we evaluated 3 men with signs and symptoms of epididymitis, who upon further examination were found to have AIDS. Two patients presented with high fever and evidence of systemic sepsis, including lethargy and confusion. Both had a large, tender scrotal mass with no obvious abscess formation, which required extended hospitalization and intravenous antibiotics. The third patient complained of testicular and epididymal tenderness that resolved after oral antibiotic therapy. All 3 patients had oral candidiasis and 1 had Cryptosporidiuminduced diarrhea. Two men had been evaluated previously for unexplained adenopathy but the results were negative. All 3 patients had pyuria but negative urine and blood cultures. Social histories placed each man in a high risk group for AIDS. In retrospect, the unusually severe presentation in conjunction with atypical infections in 2 of these cases indicated systemic immunocompromise. Although immunocompromised AIDS patients classically suffer from regional and systemic infections with organisms that proliferate because of severe T cell and associated B cell abnormalities, 3 epididymitis is not routinely considered as a common infection in this group. However, at least 1 high risk group, homosexuals, is prone to lower urinary tract infections that may be exacerbated by the immunodeficiency of AIDS. Reports of atypical organisms causing epididymitis in immunocompromised hosts 1· 2 may explain the slow resolution of symptoms in a least 1 patient treated with intravenous ampicillin and gentamicin. When acute epididymitis is accompanied by a symptom complex suggestive of AIDS, aggressive cultures for virus, fungus and atypical organisms, as well as possible transscrotal aspiration or open biopsy, may be necessary. In retrospect, the circumstances in these 3 cases demanded a more aggressive microbiological evaluation. AIDS patients may present with subtle complaints of weight loss, fatigue or infectious disease, such as pneumonia. Therefore, a high degree of suspicion is needed for the ultimate diagnosis. Although all patients who present with acute scrotal pain and fever do not necessarily have AIDS, further investigation would be warranted if other signs and symptoms were suggestive or the presentation was unusually severe. Respectfully, Daniel B. Rukstalis and Gary P. Kearney Brigham & Women's Hospital 75 Francis Street Boston, Massachusetts 02115 and William De Wolf Beth Israel Hospital 330 Brookline Avenue Boston, Massachusetts 02215
1. Wheeler, J. S., Jr., Culkin, D. J., O'Connell, J. and Winters, G.:
Nocardia epididymo-orchitis in an immunosuppressed patient. J. Urol., 136: 1314, 1986. 2. Randazzo, R. F., Hulette, C. M., Gottlieb, M. S. and Rajfer, J.: Cytomegaloviral epididymitis in a patient with the acquired immune deficiency syndrome. J. Urol., 136: 1095, 1986. 3. Bowen, D. L., Lane, H. C. and Fauci, A. S.: Immunopathogenesis of the acquired immunodeficiency syndrome. Ann. Intern. Med., 103: 704, 1985.
RE: PROGNOSIS OF UNTREATED STAGE Al PROSTATIC CARCINOMA: A STUDY OF 94 CASES WITH EXTENDED FOLLOWUP
J. I. Epstein, G. Paull, J.C. Eggleston and P. C. Walsh J. Urol., 136: 837-839, 1986 To the Editor. The authors subscribe to the criteria that less than 5 per cent of neoplasm in a prostatic specimen classifies the lesion as stage Al. As they note more stringent criteria classify stage Al disease as 3 or less foci of neoplasm in the total pathological specimen. Two particular problems come to mind. Five per cent of a 50 gm. gland (2.5 gm.) is considerably different than 5 per cent of a 10 gm. gland (0.5 gm.) in terms of pure numbers of neoplastic cells, that is 2.7 billion versus 537 million, not to mention the enormous number of cells in an 80 gm. enucleated specimen (4 gm. equals 4.3 X 109 neoplastic cells). None of the cases had a thorough repeat biopsy of the posterior aspect of the prostatic fossa (3 to 9 o'clock position) to determine if they were staged accurately as AL Any residual neoplasm would indicate that the disease was stage A2. A cubic centimeter of prostatic adenocarcinoma contains approximately 1 billion cells and represents 30 cell doublings. Such a mass would have ample opportunity to produce a "metastatic variant" cell that could implant at a distant site. In comparison 3 or less foci of disease likely represent at most thousands of cells, assuming a focus is defined as an area no larger than 100 to 200 µ. Since each prostatic cancer cell is about 10 µ. in size, the area of such a focus in 3 dimensions would contain between 1,000 and 8,000 cells. These small numbers of neoplastic cells have not had the opportunity to undergo the necessary cell doublings required to produce a metastatic variant cell. Morphometric studies by Dr. Fuad Freiha at Stanford have substantiated that tumor volume is related directly to capsular invasion, seminal vesical invasion and lymph node metastasis. Since 7 of 8 patients with progression had less than 3 foci (size ?) of neoplasm in the pathological specimen, I suspect that the critical volume, even assuming the possibility of residual disease, necessary to produce a metastatic variant cell probably did not exist at the time of initial diagnosis. As a consequence the authors' data also may be interpreted in an alternate manner: the patients referred to in this study with disease progression actually had stage A2 (residual) disease or sufficient time had elapsed during the followup period for the development de novo of an additional prostatic neoplasm. In conclusion, I suggest that more rather than less rigorous criteria be applied for stage A prostatic adenocarcinoma. Respectfully, Richard H. Bard Department of Urology Montefiore Medical Center-Albert Einstein College of Medicine 111 East 210th Street Bronx, New York 10467
Reply by Authors. Recently, we demonstrated at 4 and 8-year followup after diagnosis of stage A carcinoma that the percentage of the specimen involved by tumor was a better predictor of progression than the actual tumor volume resected. 1 As to the question of repeat biopsy we agree with Doctor Bard that since 7 of the 8 patients with progression had such small foci of tumor at initial resection, these cases were not likely to be examples of undersampling but rather they represented progression of minimal residual tumor during a long period. A recent evaluation of our radical prostatectomies done for stage Al carcinoma demonstrated that 86 per cent of the prostates contained residual tumor, which owing to its peripheral and/or apical distribution would not necessarily have been upstaged by repeat transurethral resection. 2