Benign and malignant diseases

The differential diagnosis between primary mesenteric lymphoma and others peritoneum diseases such as peritoneal carcinomatosis, malignant primary peritoneal mesotheliomas, tuberculous peritonitis, sarcomatosis, diffuse peritoneal leiomyomatosis or benign splenosis, constitutes a major problem in imaging techniques.

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Chronic Idiopathic Myelofibrosis Chronic IMF (other designations include agnogenic myeloid metaplasia or myelofibrosis with myeloid metaplasia) is a clonal disorder of a multipotent hematopoietic progenitor cell of unknown etiology characterized by marrow fibrosis, extramedullary hematopoiesis, and splenomegaly. Chronic IMF is the least common chronic myeloproliferative disorder, and establishing this diagnosis in the absence of a specific clonal marker is difficult because myelofibrosis and splenomegaly are also features of both PV and CML.

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Bone Sarcomas Incidence and Epidemiology Bone sarcomas are rarer than soft tissue sarcomas; they accounted for only 0.2% of all new malignancies and 2370 new cases in the United States in 2007. Several benign bone lesions have the potential for malignant transformation. Enchondromas and osteochondromas can transform into chondrosarcoma; fibrous dysplasia, bone infarcts, and Paget's disease of bone can transform into either malignant fibrous histiocytoma or osteosarcoma.

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Benign Disease Symptoms Benign proliferative disease may produce hesitancy, intermittent voiding, a diminished stream, incomplete emptying, and postvoid leakage. The severity of these symptoms can be quantitated with the self-administered American Urological Association Symptom Index (Table 91-2), although the degree of symptoms does not always relate to gland size. Resistance to urine flow reduces bladder compliance, leading to nocturia, urgency, and, ultimately, urinary retention.

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Metastatic Disease: Castrate Castration-resistant disease can manifest in many ways. For some it is a rise in PSA with no change in radiographs and no new symptoms. In others it is a rising PSA and progression in bone with or without symptoms of disease. Still others will show soft tissue disease with or without osseous metastases, and others have visceral spread. The prognosis, which is highly variable, can be predicted using nomograms designed for the castration-resistant disease state.

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Antiandrogens Nonsteroidal antiandrogens such as flutamide, bicalutamide, and nilutamide block the binding of androgens to the receptor. When an antiandrogen is given alone, testosterone levels remain the same or increase. Compared to testosteronelowering therapies, antiandrogens cause fewer hot flashes, less of an effect on libido, less muscle wasting, fewer personality changes, and less bone loss. Gynecomastia remains a significant problem but can be alleviated in part by tamoxifen.

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For patients with a rising PSA after radiation therapy, salvage prostatectomy can be considered if the disease was "curable" at the outset, if persistent disease has been documented by a biopsy of the prostate, and if no metastatic disease is seen on imaging studies. Unfortunately, case selection is poorly defined in most series, and morbidities are significant. As currently performed, virtually all patients are impotent after salvage radical prostatectomy, and ~45% have either total urinary incontinence or stress incontinence.

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Brachytherapy Brachytherapy is the direct implantation of radioactive sources into the prostate. It is based on the principle that the deposition of radiation energy in tissues decreases as a function of the square of the distance from the source (Chap. 81). The goal is to deliver intensive irradiation to the prostate, minimizing the exposure of the surrounding tissues. The current standard technique achieves a more homogeneous dose distribution by placing seeds according to a customized template based on CT and ultrasonographic assessment of the tumor and computer-optimized dosimetry.

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Radical Prostatectomy The goal of radical prostatectomy is to excise the cancer completely with a clear margin, to maintain continence by preserving the external sphincter, and to preserve potency by preserving the autonomic nerves in the neurovascular bundle. Radical prostatectomy is advised for patients with a life expectancy of 10 years and is performed using a retropubic, perineal, or laparoscopic approach. Outcomes can be predicted using postoperative nomograms that consider pretreatment factors and the pathologic findings at surgery. PSA failure is defined as a value above 0.

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TRUS is the imaging technique most frequently used to assess the primary tumor, but its chief use is directing prostate biopsies, not staging. No TRUS finding consistently indicates cancer with certainty. CT lacks sensitivity and specificity to detect extraprostatic extension and is inferior to MRI in visualization of lymph nodes. In general, MRI performed with an endorectal coil is superior to CT to detect cancer in the prostate and to assess local disease extent.

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Pathology The noninvasive proliferation of epithelial cells within ducts is termed prostatic intraepithelial neoplasia. PIN is a precursor of cancer, but not all PIN lesions develop into invasive cancers. Of the cancers identified, 95% are adenocarcinomas; the remainder are squamous or transitional cell tumors or, rarely, carcinosarcomas. Metastases to the prostate are rare, but in some cases colon cancers or transitional cell tumors of the bladder invade the gland by direct extension.

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The PSA criteria used to recommend a diagnostic prostate biopsy have evolved over time. The goal is to increase the sensitivity of the test for younger men more likely to die of the disease and to reduce the frequency of detecting cancers of low malignant potential in elderly men more likely to die of other causes. Age-specific reference ranges reduce the upper limit of normal for younger men and increase it for older men. Different thresholds alter the sensitivity and specificity of detection. The threshold for performance of a biopsy was 4.0 ng/mL, which has been reduced to 2.6...

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Diagnosis and Treatment by Clinical State The disease continuum—from the appearance of a preneoplastic and invasive lesion localized to the prostate, to a metastatic lesion that results in symptoms and, ultimately, mortality from prostate cancer—can span decades. Management at all points is centered on competing risks that are defined by considering the disease as a series of clinical states (Fig. 91-1).

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Harrison's Internal Medicine Chapter 91. Benign and Malignant Diseases of the Prostate Benign and Malignant Diseases of the Prostate: Introduction Benign and malignant changes in the prostate increase with age. Autopsies of men in the eighth decade of life show hyperplastic changes in 90% and malignant changes in 70% of individuals. The high prevalence of these diseases among the elderly, who often have competing causes of morbidity and mortality, mandates a risk-adapted approach to diagnosis and treatment. This can be achieved by considering these diseases as a series of states.

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Gastric (Nonlymphoid) Sarcoma Leiomyosarcomas and GISTs make up 1–3% of gastric neoplasms. They most frequently involve the anterior and posterior walls of the gastric fundus and often ulcerate and bleed. Even those lesions that appear benign on histologic examination may behave in a malignant fashion. These tumors rarely invade adjacent viscera and characteristically do not metastasize to lymph nodes, but they may spread to the liver and lungs. The treatment of choice is surgical resection. Combination chemotherapy should be reserved for patients with metastatic disease.

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Several additional etiologic factors have been associated with gastric carcinoma. Gastric ulcers and adenomatous polyps have occasionally been linked, but data on a cause-and-effect relationship are unconvincing. The inadequate clinical distinction between benign gastric ulcers and small ulcerating carcinomas may, in part, account for this presumed association. The presence of extreme hypertrophy of gastric rugal folds (i.e.

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Harrison's Internal Medicine Chapter 80. Cancer Cell Biology and Angiogenesis Cancer Cell Biology and Angiogenesis: Introduction Two characteristic features define a cancer: unregulated cell growth and tissue invasion/metastasis. Unregulated cell growth without invasion is a feature of benign neoplasms, or new growths. Cancer is a synonym for malignant neoplasm. Cancers of epithelial tissues are called carcinomas; cancers of nonepithelial (mesenchymal) tissues are called sarcomas. Cancers arising from hematopoietic or lymphoid cells are called leukemias or lymphomas.

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Table 38-2 Esophageal Dysphagia Esophageal Mechanical Dysphagia I. Wall defects A. Congenital B. Tracheoesophageal fistula II. Intrinsic narrowing A. Inflammatory esophagitis 1. Viral (herpes simplex, varicella-zoster, cytomegalovirus) 2. Bacterial 3. Fungal (Candida) 4. Mucocutaneous bullous diseases 5. Caustic, chemical, thermal injury 6. Eosinophilic esophagitis B. Webs and rings 1. Esophageal (congenital, inflammatory) 2. Lower esophageal mucosal ring (Schatzki's ring) 3. Eosinophilic esophagitis 4. Host-versus-graft disease, mucocutaneous disorders C.

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