Prostate specific antigen level and Gleason score in predicting the stage of newly diagnosed prostate cancer.

The purpose of this study was to determine the utility of prostate specific antigen (PSA) level and Gleason score in the prediction of disease stage in men with newly diagnosed prostate cancer. 102 consecutive men, newly diagnosed with prostate cancer and candidates for radical therapy, underwent contrast enhanced pelvic CT and skeletal scintigraphy. Staging examinations used the TNM classification and were reported prospectively with the radiologist blinded to the patient's Gleason score and level of PSA. Lymph node metastasis was confirmed by CT guided biopsy, lymphadenectomy or response to therapy in some cases of massive disease. There were significant differences between the mean PSA values of 18 men with and 84 men without skeletal metastases (p = 0.01) and between men with locally confined and non-confined disease (p = 0.02). There was no difference between PSA values of 13 men with and 89 men without lymph node metastasis (p = 0.9). Only one man with CT evidence of nodal metastasis (N + ve) had a PSA value below 20 ng ml-1. Two men with Gleason scores below 6 were N + ve and both had PSA values over 20 ng ml-1. One man with skeletal metastasis had a PSA value below 20 ng ml-1 but had bone pain. For this study group if only those men with PSA values over 20 ng ml-1 had been examined, sensitivity for lymphatic and skeletal metastasis would have been 92%. Using this threshold about one-third would have been spared imaging investigation. In conclusion, pelvic CT and skeletal scintigraphy are unlikely to show metastatic disease in a man newly diagnosed with prostate cancer who has no suggestive clinical features, a PSA level below 20 ng ml-1 and a Gleason score below 6.     

Is bone scintigraphy necessary in initial staging of prostate cancer patients?

Our aim was to determine whether serum prostate specific antigen (PSA) and total Gleason score (GS) on biopsy in newly diagnosed prostate cancer (PCa) can predict osseous metastases and eliminate the need for a bone scan as a routine procedure in initial staging. We studied retrospectively 155 patients with previously untreated PCa who underwent bone scintigraphy. Relationship between PSA, GS and bone metastases was examined. Sensitivity, specificity, likelihood ratio (LR) and odds ratio (OR) were calculated with corresponding 95% conidence interval. Results showed that thirty of all bone scans (19.35%) were positive for metastases. This proportion was significantly higher in patients with PSA>20ng/mL (31.66% , P=0.002) vs. PSA<10ng/mL (10.52%). For PSA<10ng/mL as well as 10ng/mL≤ PSA≤ 20ng/mL the test was not a predictor for bone metastases (OR=0.36; OR=0.55). For PSA>20 ng/mL (OR=3.53) the likelihood of bone metastases was increased by 13% . The proportion of positive scintigraphy findings was significantly lower in patients with GS≤ 7 (11.47% ) vs. GS≥ 8 (48.48% , P<0.0001). The GS≥ 8 was highly predictive for bone metastases (OR=7.260). The analysis showed that GS≥ 8 increases the risk of bone metastases by 29%. In conclusion, bone scintigraphy is not necessary in asymptomatic patients with localized disease, GS≤ 6 and PSA<10ng/mL, because of the negligible risk of bone metastases in that stage. Higher levels of GS and PSA may predict bone metastases.     

Serum bone alkaline phosphatase levels enhance the clinical utility of prostate specific antigen in the staging of newly diagnosed prostate cancer patients.

The aim of this study was to analyse the clinical utility of serum bone alkaline phosphatase (BAP) in addition to prostate-specific antigen (PSA) in the staging of newly diagnosed untreated prostate cancer patients. A prospective study was conducted, analysing serum BAP and PSA concentrations in 295 consecutive newly diagnosed untreated prostate cancer patients (T1-4, N0-1, M0-1b), 93 of whom had bone metastases on bone scan. The relationship of each marker with extent of bone disease, the influence of several clinical variables on both serum marker levels, the efficiency in predicting bone metastasis through receiver operating characteristic curves and, finally, the clinical utility in avoiding unnecessary bone scans were determined. Significant differences were found in the serum levels of both BAP and PSA between patients with and patients without bone metastases. Multiple regression analysis showed the extent of bone disease to be the only variable that influenced both serum levels. However, while serum BAP levels showed a statistical relationship with extent of bone disease, serum PSA levels did not. The best prediction of bone scan findings was obtained with the combination of both markers using a cut-off of 20 ng/ml, with positive and negative predictive values of 46.5% and 100%, respectively. This greater efficiency could permit 32.2% of initial bone scans to be avoided. False-positive and false-negative rates of BAP were 7.5% and 14%, respectively. This study suggests that serum BAP levels could play a complementary role in the diagnosis of bone metastasis in prostate cancer patients. This marker could provide useful clinical information on the degree of skeletal metastasis and constitute an easy way of enhancing the clinical utility of PSA. The addition of this marker to PSA in the initial evaluation could permit staging bone scan to be avoided at a PSA range of 10-20 ng/ml, with significant implications for cost saving.     

Association of prostate-specific antigen levels and patterns of benign and malignant uptake detected. on bone scintigraphy in patients with newly diagnosed prostate carcinoma

The bone scan patterns of benign and malignant uptake in 432 patients with newly diagnosed prostate carcinoma were reviewed in relation to prostate-specific antigen (PSA) levels determined within 4 months of scintigraphy. Scan results were categorized in terms of likelihood of metastatic disease and anatomical locations of benign and malignant lesions were tabulated. At least one suspect focus was identified in 138 scans (32%), and metastatic bone disease was present in 38 (9%). Metastatic disease prevalence increased from 1% for PSA <20 ng x ml(-1) to 58% for PSA>100 ng x ml(-1). Among patients with PSA>20 ng x ml(-1) (n = 157), 70 (45%) had at least one bone scan finding of concern for metastases and 35 (22%) proved to have metastatic disease. Almost all scans with metastases had either limited disease (< or = 5 suspicious lesions; n = 16; 42%) or extensive metastases (> 20 abnormalities; n = 19; 50%). The majority of patients with limited skeletal metastases had PSA < 100 ng x ml(-1) (11/16; 69%), while almost all patients with extensive skeletal involvement had PSA >100 ng x ml(-1) (17/19; 89%). Among those with limited metastatic disease, most (13/16; 81%) had at least one lesion in the pelvis or sacrum; the next most common sites were in the thoracic and lumbar spine (six each; 38%). In scans with a low to moderate suspicion for bone metastases, the only anatomical site with a significantly higher prevalence of malignant than benign lesions was the pelvis.     

The clinical utility of prostate-specific antigen and bone scintigraphy in prostate cancer follow-up.

To assess the value of serum prostate-specific antigen (PSA) in prostate cancer follow-up, we prospectively studied 107 consecutive patients with: (1) pathologically confirmed prostate cancer; (2) definitive prostatectomy and/or radiation therapy greater than or equal to 3 mo prior to bone scanning; and (3) one bone scan and serum PSA sampling within 3 mo of each other. The mean and range of patient follow-up since definitive therapy was 1.6 and 0.5-8 yr, respectively. Abnormal bone scans were correlated with pertinent radiographs. Of 107 bone scans, 16 demonstrated metastatic bone disease. A PSA value of less than or equal to 8 ng/ml excluded bone metastases with a predictive value of a negative test of 98.5%. Without radiographic correlation, abnormal bone scans rarely represented metastases if the PSA value was less than or equal to 8 ng/ml. In summary, serum PSA concentration determines the need for follow-up bone scanning and assists in scan interpretation in patients status post definitive therapy for prostate cancer.     

Serum bone alkaline phosphatase levels enhance the clinical utility of prostate specific antigen in the staging of newly diagnosed prostate cancer patients

The aim of this study was to analyse the clinical utility of serum bone alkaline phosphatase (BAP) in addition to prostate-specific antigen (PSA) in the staging of newly diagnosed untreated prostate cancer patients. A prospective study was conducted, analysing serum BAP and PSA concentrations in 295 consecutive newly diagnosed untreated prostate cancer patients (T1–4, N0–1, M0–1b), 93 of whom had bone metastases on bone scan. The relationship of each marker with extent of bone disease, the influence of several clinical variables on both serum marker levels, the efficiency in predicting bone metastasis through receiver operating characteristic curves and, finally, the clinical utility in avoiding unnecessary bone scans were determined. Significant differences were found in the serum levels of both BAP and PSA between patients with and patients without bone metastases. Multiple regression analysis showed the extent of bone disease to be the only variable that influenced both serum levels. However, while serum BAP levels showed a statistical relationship with extent of bone disease, serum PSA levels did not. The best prediction of bone scan findings was obtained with the combination of both markers using a cut-off of 20 ng/ml, with positive and negative predictive values of 46.5% and 100%, respectively. This greater efficiency could permit 32.2% of initial bone scans to be avoided. False-positive and false-negative rates of BAP were 7.5% and 14%, respectively. This study suggests that serum BAP levels could play a complementary role in the diagnosis of bone metastasis in prostate cancer patients. This marker could provide useful clinical information on the degree of skeletal metastasis and constitute an easy way of enhancing the clinical utility of PSA. The addition of this marker to PSA in the initial evaluation could permit staging bone scan to be avoided at a PSA range of 10–20 ng/ml, with significant implications for cost saving. Received 4 December 1998 and in revised form 15 February 1999     

The clinical value of prostate-specific antigen and bone scintigraphy in the staging of patients with newly diagnosed,pathologically proven prostate cancer

Recent reports suggest that radionuclide bone scan (BS) may not be necessary in the standard staging evaluation of patients with prostate cancer when serum prostate-specific antigen (PSA) levels are normal. To evaluate the ability of PSA to predict BS findings, we retrospectively reviewed the case records of 118 consecutive patients (median age 73 years, range 50–90 years) with newly diagnosed, untreated, pathologically proven prostate cancer who underwent BS and serum PSA sampling within a period of no more than 3 months. Fifty-four out of 118 BSs demonstrated metastatic bone disease. A PSA value of less then 10 ng/ml excluded bone metastasis; of 35 patients with a serum PSA level of 20 ng/ml or less, seven had a positive BS (negative predictive value of 80%). These findings provide additional confirmation of the value of low serum PSA concentrations in excluding the need for a staging BS, although the threshold for a high value of negative predictive accuracy is lower than previously reported.     

[18F]fluorocholine PET/CT imaging for the detection of recurrent prostate cancer at PSA relapse: experience in 100 consecutive patients

Purpose We evaluated the potential of PET/CT and [¹⁸F]fluoromethylcholine (FCH) in the assessment of suspected recurrence of prostate cancer after treatment. Methods One hundred consecutive prostate cancer patients with a persistent increase in serum PSA (>0.1 ng/ml) after radical prostatectomy (58 cases), radiotherapy (21 cases) or hormonal therapy alone (21 cases) were investigated. After injection of 3.7–4.07 MBq/kg of FCH, both early (at <15 min) and delayed (at >60 min) PET/CT scans were performed in 43 patients, delayed PET/CT scans in 53 patients and early PET/CT scans in four patients. Results Of the 100 patients, 54 (PSA 0.22–511.79 ng/ml) showed positive FCH PET/CT scans. Thirty-seven patients had bone and/or abdominal lymph node uptake, while 17 showed pelvic activity. Malignant disease was confirmed in all but one. Delayed SUV_max of bone metastases was significantly higher (p<0.0001 by paired t test) than that measured at <15 min, whereas no differences were observed between early and delayed SUVs of malignant lymph nodes or pelvic disease. Forty-six patients (PSA 0.12–14.3 ng/ml) showed negative FCH PET/CT scans. Of the negative PET/CT scans, 89% were obtained in patients with serum PSA <4 ng/ml and 87% in patients with a Gleason score <8. In none of these cases could recurrent tumour be proven clinically during a follow-up of 6 months. Conclusion FCH PET/CT is not likely to have a significant impact on the care of prostate cancer patients with biochemical recurrence until PSA increases to above 4 ng/ml. However, in selected patients, FCH PET/CT helps to exclude distant metastases when salvage local treatment is intended.     

Correlation of procollagen (I) with prostate specific antigen and bone scan for the diagnosis of bone metastases in patients with prostate carcinoma

Procollagen (I) carboxyterminal propeptide (PICP) is a metabolite of procollagen, a precursor molecule of collagen type I, which accounts for more than 90% of the organic matrix of the bones. Serum PICP levels indicate the rate of bone collagen synthesis and therefore the osteoblastic activity. In this study we evaluate the clinical usefulness of serum PICP as an indicator of bone metastases in patients with prostate cancer in relation to bone scan and to prostate specific antigen (PSA) measurements. We found no similar study in the literature relating these three tests. Seventy-eight patients (median age 63+/-4,3 years) with prostate adenocarcinoma were examined. The diagnosis was confirmed histologically. Bone metastases were diagnosed in 42 (54%) of them assessed by bone scans (Group A), while the remaining 36 patients (46%) had no bone metastases (negative bone scans and X-rays) (Group B). We also examined 21 patients with benign prostate hyperplasia as a control group (Group C). All patients had serum PICP measurements, bone scans with (99m)Tc-MDP and PSA measurements. None of them had a history of disease or of using drugs known to affect bone metabolism. Serum levels of PICP were assayed by a radioimmunoassay (RIA) kit (Orion Cooperation, Farmos Diagnostics, Finland). Serum PSA was also tested by a RIA kit (Tandem-R, Hybritech Inc, USA). PICP levels in Group A were 265+/-89 microg/l, in Group B 128+/-39 microg/l and in Group C patients 110+/-48 microg/l. High levels of PICP above 170 microg/l, were diagnostic of bone metastases with sensitivity 54%, specificity 93% and accuracy 84%. In comparison, PSA levels above 4 ng/ml were also diagnostic with a sensitivity of 68%, specificity of 91% and accuracy 88%. Patients with low levels of PICP, lower than 90 microg/l, n=31, had no bone metastases. The positive prognostic value of bone scan was 74% with a sensitivity of 76%, specificity of 58% and accuracy 71%. Positive bone scans combined with very high levels of PICP and PSA, had positive prognostic value 97%, with sensitivity of 78%, specificity of 96% and accuracy 97%, while bone scans with levels of PICP lower than 170 microg/l, had positive prognostic value of 32%. Levels of PICP and PSA were significantly higher in patients with prostate cancer and bone metastases in comparison to patients with benign prostate hyperplasia (P<0.0001) respectively. Also, levels of PICP and PSA were higher in patients with prostate cancer without metastases as compared to prostate hyperplasia (P<0.0005 and P<0.0001 respectively) (Wilcoxon-Mann-Whitney test). When metastases were more extensive, PICP levels were higher than PSA. It is concluded that PICP as a marker of osteoblastic activity is useful for diagnosing bone metastases of prostate adenocarcinoma but when co-evaluated with PSA and the bone scan, the diagnostic accuracy of these three diagnostic procedures is much higher.     

Four prognostic indices in advanced prostate cancer patients, under palliative androgen deprivation treatment

Prostate cancer (PCa) is the second leading cause of death in men aged 40 years and older ]and prognostic indices are useful in suggesting its proper treatment. The aim of this study was to evaluate the prognostic value of Gleason score (GS), TNM staging system, initial serum prostate specific antigen (PSA) and bone scintigraphy (BS) in patients with PCa under hormonal palliative treatment, in the development and progression of recurrent PCa. Our methods were as follows: Between January 2005 and December 2007, we have studied at the University General Hospital of Alexandroupolis fourty patients of mean age 77+/-7.2 years with advanced PCa under palliative treatment with antiandrogens and luteinizing hormone-releasing hormone analogues. PCa was diagnosed histologically, based on the TNM system after transrectal ultrasonography guided biopsy. The Gleason score assessment was made as described by others. Metastases were confirmed by a positive bone scintigraphy with 925 MBq (99m)Tc-MDP using a tomographic gamma camera, computerized axial tomography or magnetic resonance imagining. Measurements of PSA were conducted by the radioimmunoassay method. We also examined 20 healthy blood donors (median age 45+/-6.1 years) as controls, in order to estimate the cut-off value of PSA. Our results show the following: Thirteen of our patients had 1-6 "hot" spots and 27 had more than 6 "hot" spots in the bone scan. The median Gleason score was 7 (modal Gleason score 3+4). Serum PSA levels were higher in patients with PCa and bone metastases in comparison to those with PCa without bone metastases. Very high values of PSA (more than 50 ng/ml) were found in patients with multiple bone metastases (>6 "hot" spots). In conclusion, our findings demonstrate that the prognostic value of GS (P=0.043), TNM staging (P=0.1410), serum PSA levels (P=0.002) and BS (P=0.0135) when used alone, not always improve the prognosis to hormone indepentent but when combined (P<0.001) increase the prognosis in patients with advanced PCa under hormonal palliative treatment.     

Power Doppler Imaging and prostate cancer: optional or necessary technique?

PURPOSE: To evaluate the value of power Doppler sonography (PDS) in patients with a serum PSA level greater than 3.5 ng/ml and note the advantages of PDS in management of biopsy cores and staging in prostate cancer. MATERIAL AND METHODS: A group of 579 patients with a serum PSA level greater than 3.5 ng/ml underwent sextant biopsies. PDS of the prostate was performed in all patients before biopsy indication. Patients underwent six initial sextant biopsies without Doppler. In 141 patients who retained an elevated serum PSA level, an additional series of six to eight ultrasound-guided biopsies with Doppler were indicated. A total of 299 cancers were diagnosed (126 palpable) after initial biopsies and 85 (13 palpable) after additional biopsies. One hundred seven patients with localized cancer (48 palpable) underwent a radical prostatectomy. RESULTS: An echographic or vascular anomaly was detected in 335 patients; after biopsies this anomaly corresponded to 260 cancers, 39 of which were not visible (false-negative Doppler results). The negative predictive value was 84% and there was no significant relation between PSA level and negative predictive value. After initial biopsies, if an abnormal Doppler signal was present the risk of having positive additional biopsies was 83%. Abnormal disoriented irregular vessels were present in 69% of patients with a Gleason score of 7 or higher versus 31% in patients with a Gleason score less than 7 (p<0.01). Twenty out of 39 patients with T1c cancer invisible with PDS and not palpable (13% of all cancers) underwent a radical prostatectomy. Eleven of 16 cancers with a Gleason score of 6 or less were found insignificant, but in two cases the lesion was advanced (p<0.01). Of cancers with a tumor vessel crossing the capsule, 71% presented an extraprostatic extension (Se: 37.5%, Spe: 93%, PPV: 71%, NPV: 78%) (p<0.01). CONCLUSION: In prostatic cancer, PDS allows evaluation of aggressiveness features and can optimize the number of useful biopsy cores.     

Interstitial implant alone or in combination with external beam radiation therapy for intermediate-risk prostate cancer: a survey of practice patterns in the United States

PURPOSE: This study is aimed at understanding and defining the current patterns of care with respect to prostate brachytherapy for patients with intermediate-risk localized disease in the combined academic and community setting. METHODS AND MATERIALS: A nomogram-based survey was developed at the Seattle Prostate Institute defining the accepted criteria for intermediate-risk prostate cancer. Patients were defined as having intermediate-risk prostate cancer if they met one of the following criteria: prostate-specific antigen (PSA) >10 ng/dL, Gleason score (GS) > or = 7, or cT2b or cT2c disease. Additional potential predictive factors including perineural invasion (PNI), GS 3+4 vs. 4+3, and high-volume disease were included. RESULTS: In the absence of PNI, all of those surveyed would perform monotherapy for intermediate-risk patients, GS 7 (3+4) or PSA 10-20, with cT1c and <30% cores +. Up to 80% would perform monotherapy for patients with cT1c, GS 7 (4+3), and <30% cores +. Eighty to 90% of physicians would perform an implant alone with cT2a and either a PSA of 10-20 or GS of 7 (3+4) and <30% cores +. Fifty to 60% of those surveyed stated that they would treat a patient with cT2b disease, GS 7 (3+4), or PSA 11-20, with less than two-thirds of the biopsy cores positive in the absence of PNI. CONCLUSIONS: This Patterns of Care (POC) study reveals that certain subsets of intermediate-risk localized prostate cancer patients are considered appropriate candidates for an interstitial implant alone.     

Magnetic resonance spectroscopy in patients with locally confined prostate cancer: association of prostatic citrate and metabolic atrophy with time on hormone deprivation therapy, PSA level, and biopsy Gleason score

This study was undertaken to determine respective associations between prostatic citrate or metabolic atrophy (no detectable citrate, choline, and creatine) at magnetic resonance spectroscopy (MRS) and time on hormone-deprivation therapy, serum PSA, and biopsy Gleason score. Clinical data, histopathology reports and PSA levels of 36 patients on hormone-deprivation therapy (age, 64±9 years, pre-therapeutic biopsy Gleason sum, median 6, range 3–8, antiandrogens only, n=3, LHRH-analogues only, n=4, combined hormone-deprivation therapy, n=29, duration, 27±19 weeks) for locally confined prostate cancer (PCA) were retrospectively correlated with findings in the peripheral zone of the prostate at 3D-MRS (endorectal coil, PRESS, TR 1,000 ms, TE 130 ms). The results show that citrate was usually detected after 13 weeks or less of hormone-deprivation therapy (10/12 vs. 6/24 patients, chi-square-test, p=0.002). All patients with PSA levels exceeding 0.20 ng/ml had detectable metabolites (citrate, n=12, choline without citrate, n=6), while 9/18 patients with PSA 0.20 ng/ml or less showed metabolic atrophy (Fisher-exact-test, p=0.001). There were no significant associations between citrate, metabolic atrophy, pre-therapeutic PSA, and biopsy Gleason sum, respectively. It has been concluded that hormone-deprivation therapy for locally confined PCA has not reached its full deprivation potential after 13 weeks. MRS detects prostate metabolism in patients with PSA exceeding 0.20 ng/ml after hormone-deprivation therapy.     

A case report of distant lymph nodes metastases from prostate cancer imaged with 201Tl and 99mTc-MIBI

Prostate cancer most often metastases to regional lymph nodes and bones by hematogeneous or lymphatic spread. The authors present a rare case of metastatic prostate cancer to supradiaphragmatic lymph nodes that were detected on 201Tl and 99mTc-MIBI imaging and confirmed on a CT scan. An 81-yr-old man with bilateral painful cervical lymphadenopathies was referred to our hospital with suspected thyroid cancer. The US and thyroid scan indicated no abnormalities in his thyroid gland. Both 201Tl and 99mTc-MIBI scans showed multiple areas of abnormally increased radioactivity in both supraclavicular, anterior mediastinum, and bilateral hilar regions. A CT scan also revealed multiple lymphadenopatheis in the same regions as radionuclide scans. Prostate cancer was diagnosed from the results of immunohistochemical staining for PSA examination of a biopsy specimen of the mediastinal lymph node. The serum PSA concentration was markedly elevated at 490 ng/ml (normal, < 40 ng/ml). Both 99mTc-HMDP bone and 67Ga scans were normal. All supradiaphragmatic lymph nodes on CT images disappeared 2 months after subcapsular orchiectomy and endocrine treatment with Bicalutamide. Metastatic prostate cancer should be considered when metastatic adenocarcinoma is discovered in the supraclavicular lymph nodes of elder men.     

The value of pretreatment clinical and biochemical parameters in patients with newly diagnosed untreated prostate carcinoma and no indications for bone metastases on the bone scintigram

Between 10% and 25% of patients with newly diagnosed prostate cancer without bone metastases at the time of diagnosis will develop metastases during follow-up. To determine the value of clinical and biochemical parameters for assessment of prognosis at the time of diagnosis, a retrospective study was performed in 124 consecutive patients with newly diagnosed prostate cancer without bone metastases. The mean follow-up was 41 months, during which time 36 patients died and 15 patients developed metastases. Bone scans were classified from 0 (=normal) through 2 (=abnormal, but not typical for metastases) and were correlated with age, alkaline phosphatase (AP), prostate-specific antigen (PSA), tumour grade, T-stage and N-stage. In patients with a class 2 scan, additional roentgenograms and follow-up were used to exclude metastases at initial stage. All parameters, including therapy, were finally correlated with the development of metastases and survival. For survival 38 patients with proven metastases were used as controls. For all parameters tested, no statistically significant differences were found between the three bone scan classifications. The interval between diagnosis and the development of metastases ranged from 12 to 72 months. For the risk of development of metastases only PSA was found to be a significant correlate (P=0.0075). However, when tumour stages were clustered in limited disease (T0–2) and extensive disease (T3–4), the incidence of metastases was significantly higher in patients with extensive disease than in those with limited disease (P=0.0021). Finally, age, PSA and Anderson classification were found to be significant correlates of survival, but in stepwise analysis PSA was selected as the most prognostic variable (P<0.0001). In contrast with a typical pattern of metastases on bone scintigraphy, an abnormal scan (class 1 and 2) at the time of diagnosis is not a poor prognostic parameter of the risk of death. In conclusion, in patients with prostate cancer without bone metastases at the time of diagnosis, pretreatment PSA and tumour stage can be used for the assessment of risk of development of metastases during follow-up and survival. For this purpose, tumour stage should be clustered in limited and extensive disease. Received 14 April and in revised form 9 June 1997     

Transperineal Permanent Seed Implantation of “Low-Risk” Prostate Cancer

PURPOSE: To evaluate 5-year prostate-specific antigen (PSA) relapse-free survival of transperineal permanent seed implantation (TPSI) in 118 patients with "low-risk" prostate cancer, that means stage cT1c-T2a, Gleason Score < 7, and initial PSA value < 10 ng/ml. PATIENTS AND METHODS: From 04/1999 to 06/2002, a total of 118 patients underwent a mono-TPSI, using ultrasound-based preplanning and intraoperative verification by both ultrasound and conventional fluoroscopy as well as postoperative CT planning. Patients were monitored during the 1st year in 3-month intervals, and in 6-monthly intervals from then onward. Biochemical failure was defined according to ASTRO criteria with three consecutive PSA rises observed from a posttreatment nadir PSA value. The median follow-up was 48.9 months (range: 37.0-80.2 months). 114 patients were eligible, four patients were lost to follow-up. RESULTS: For the entire group, PSA relapse-free survival at 5 years was 94.7%, with six patients (5.3%) having a PSA relapse between 8 and 20 months after implantation. In the bNED patients (no biochemical evidence of disease), PSA values were < 0.2 ng/ml in 82.5% (94/114 patients), < 0.5 ng/ml in 13.2% (15/114 patients), < 1.0 ng/ml in 2.6% (3/114 patients), and < 1.5 ng/ml in 1.7% (2/114 patients). In summary, PSA values < 0.2 ng/ml, < 0.5 ng/ml and < 1.0 ng/ml occurred in 82.5%, 95.7% and 98.3%, respectively. Out of the six patients with recurrent disease, three had a local tumor recurrence only, and three developed distant metastases. CONCLUSION: In low-risk prostate cancer patients, TPSI with intraoperative ultrasound-based treatment planning and fluoroscopy leads to excellent local tumor control and PSA relapse-free survival.     

Changing the referral criteria for bone scan in newly diagnosed prostate cancer patients

Objectives

The aim of this study was to correlate the prostate-specific antigen (PSA) level and Gleason score with staging bone scan result in patients with a new diagnosis of prostate cancer in order to establish the feasibility of implementing the European Association Urology guidelines, which state that a bone scan may not be indicated when PSA <20 in well–moderately differentiated tumours.

Methods

We identified 633 patients retrospectively and 186 patients prospectively with a new diagnosis of prostate cancer undergoing a staging bone scan between March 2005 and January 2010. Patients were excluded if there was no Gleason score available or if the PSA level was checked over 3 months prior to bone scan. Bone scan results were analysed with respect to age, PSA level and Gleason score. In the case of an equivocal result, subsequent imaging was taken into consideration or the initial bone scan was re-reviewed. In persistently equivocal cases, all relevant imaging was assessed by a blinded panel of radiologists to allow a final decision to be made.

Results

Of 672 patients aged 39–93 years (median 71 years), who fulfilled the inclusion criteria, 54 (8%) had evidence of bony metastases. PSA level and Gleason score were both independent predictors of bone scan positivity and their predictive value was additive p<0.01. None of the 357 patients with a PSA level of <20 and a Gleason score of <8 had a positive bone scan.

Conclusion

Staging bone scans in newly diagnosed prostate cancer patients with a PSA level of <20 and a Gleason score of <8 can be safely omitted, with these criteria having a negative predictive value of 100% in our series.Prostate cancer is currently the most common malignancy diagnosed in men in the UK [1] and bone is the second most common site of metastasis [2]. Bone metastases are present in up to 14% of patients at presentation [3] and in 80–85% of those who die of the disease [4], and they therefore affect morbidity, reflect prognosis and significantly influence decisions with regard to patient management.Sensitivity of planar bone scan for the detection of bone metastases is 72–77% in adults [5,6] and is currently the investigation of choice. However, it lacks diagnostic specificity, with indeterminate results often prompting the need for further imaging.Prostate-specific antigen (PSA) level is an established prognostic marker that correlates with bone scan positivity, and various studies demonstrate a low risk of a positive bone scan in newly diagnosed patients with a low PSA level [3,4,7-13]. Gleason score is also of important prognostic significance and has been shown to be an independent predictor of bone scan results on multivariate analysis [4,7,12,14]. There is still a lack of consensus, however, on the referral criteria for bone scan in low-risk patients, with different authors supporting various cut-off levels of PSA, with some including Gleason score and clinical stage. The European Association of Urology (EAU) guidelines, updated in March 2009, recommend that staging bone scan may not be indicated in patients with a PSA level of <20 with moderately to well-differentiated tumours in the absence of bony symptoms [15], while the American Urological Association and American Joint Committee on Cancer (AJCC) both recommend that staging bone scan is indicated in patients with a Gleason score of >7 or a PSA level of >20 prior to treatment [14].Despite this, there remains a large demand for isotope bone scanning in patients with a new diagnosis of prostate cancer regardless of risk stratification based on these prognostic tools.The purpose of the current study was to correlate PSA levels and Gleason scores with bone scan results in patients with newly diagnosed prostate cancer, with the aim of identifying a subgroup of patients who did not require staging bone scan, and assess the feasibility and safety of implementing EAU guidelines.     

Value of MR-US fusion in guidance of repeated prostate biopsy in men with PSA < 10 ng/mL

PurposeWe want to investigate whether MR-US fusion can improve the detection rates of clinically significant prostate cancer in patients with prior negative prostate biopsy with PSA level <10 ng/mL.MethodsThirty nine patients who had previous a history of negative prostate biopsy and PSA levels <10 ng/mL were included in this study. MR was performed before the biopsy and graded using PIRADS V2. We labeled patients with index lesions with PIRADS scores of 3 or above as the MR-positive group, while patients with PIRADS scores of 1 or 2 were the MR-negative group. Two cores of added biopsy (AB) were performed per each index lesion under MR-US fusion. Twelve cores randomized systematic biopsy (SB) were followed. In MR negative group, two cores of AB were obtained in transition zone, followed by SB. Overall cancer and clinically significant cancer detection rates by patients and by cores were analyzed, and compared between MR-positive and negative group.ResultsThe overall cancer detection rates were 51.3% by patient based and 13.8% by core based. While all of AB positive cancer patients were clinically significant cancer patients, five out of seven (71.4%) AB negative cancer patients were clinically insignificant cancer patients. AB results turned another four cancer patients from insignificant to significant cancer. The cancer detection rates between MR-positive and negative group were statistically significant.ConclusionsAdditional biopsy using MR–US fusion showed improved detection of clinically significant prostate cancer.