Results of radioiodine therapy in 47 patients with distant metastases of differentiated thyroid carcinoma

In the last ten years, 47 patients with distant metastases of differentiated thyroid carcinoma have been treated with 131I following total thyroidectomy. Post-therapy whole body 131I scans revealed detectable uptake in the metastatic lesions in 23 (62%) of 37 patients with lung metastases, 10 (67%) of 15 patients with bone metastases five (71%) of seven patients with mediastinal metastases, and neither of two patients with brain metastases. The concentration of 131I in the metastases was significantly correlated with serum T3 and T4 concentrations, and inversely correlated with serum TSH concentrations. Most of the patients with a strong positive scan were euthyroid, suggesting that thyroid hormones produced by the tumor compensated for hypothyroidism following total thyroidectomy. There was no significant relationship between serum thyroglobulin concentration during T4 replacement therapy and 131I uptake or the efficacy of therapy. Twenty patients with lung (54%), five with bone (33%), two with mediastinal (29%), and none with brain metastases showed tumor regression after treatment. Significantly increased 131I uptake in lung metastases, better therapeutic results and better prognosis were demonstrated in young patients. In conclusion, age, 131I whole body scanning and serum thyroid hormone concentrations are considered to be useful in predicting the efficacy of 131I treatment for distant metastases, especially in the lung.     

Role of skeletal scintigraphy in advanced retinoblastomas

PURPOSE: To document the incidence of skeletal metastases exclusively in advanced cases of retinoblastoma and to rationalize the use of preoperative skeletal scintigraphy in such patients. MATERIAL AND METHODS: Preoperative bone scans of 36 consecutive patients with advanced retinoblastoma who underwent skeletal scintigraphy during 1998 to 2003 were analyzed retrospectively. Bone scans were classified as: Grade 1 (high probability scan for skeletal metastases), Grade 2 (equivocal malignant or benign abnormalities), or Grade 3 (normal or certainly benign lesions). RESULTS: Grade 1 scan was found in 3 (8.33%) patients; bone metastases were confirmed by additional investigations. Grade 2 scan was found in 5 (13.88%) patients; bone metastases were excluded in all by additional investigations. Grade 3 scan was found in the remaining 28 (77.77%) patients. Extraorbital extension of disease was demonstrated by fine needle aspiration of lymph nodes in five patients, which included all three patients with Grade 1 scan. In addition to lymph node metastases, two patients had intracranial extension of the disease; demonstrated by contrast-enhanced magnetic resonance imaging of the head. One patient had liver metastases detected on abdominal ultrasound. None of the patients had skeletal metastases only. CONCLUSION: Routine preoperative bone scan is not justified in patients with locally advanced retinoblastoma. Bone scan should only be performed in patients with documented extraocular metastatic disease.     

Predictive value of bone marrow accumulation of Tc-99m tetrofosmin for subsequent development of distant metastases in breast cancer

OBJECTIVE: We evaluated the predictive value of bone marrow accumulation of technetium (Tc)-99m tetrofosmin in patients with breast cancer for distant metastases in comparison with conventional prognostic factors such as clinical stage, tumor size, axillary lymph node (Node) status, and estrogen receptor (ER) status. METHODS: Bone marrow scans with Tc-99m tetrofosmin were performed on 64 patients with breast cancer who had no clinical evidence of distant metastases. Accumulation in the femoral marrow was classified into four patterns, no detectable, lower, higher, and intensively higher. Higher or intensively higher pattern was interpreted as abnormal. Thirty-six patients with abnormal accumulation (marrow-positive group) and 28 patients without abnormal accumulation (marrow-negative group) were enrolled in the follow-up study. The mean length of observation after scans was approximately 3 years. The predictive value of femoral marrow status and conventional prognostic factors for distant metastases was evaluated by statistical analysis. RESULTS: Univariate analysis showed a significantly higher incidence of subsequent bone metastases (36%>4%; P<0.005), and distant metastases (69%>18%; P<0.001) in the marrow-positive group when compared with the marrow-negative group. Conventional prognostic factors except tumor size were also significantly associated with the development of distant metastases; 77% in clinical stage 3>39% in clinical stages 1, 2, P<0.05; 64% in Node-positive>29% in Node-negative, P<0.01; and 70% in ER negative>27% in ER positive, P<0.005. These conventional factors were not significantly associated with bone metastases. The Cox proportional hazard ratio for bone metastases was markedly higher in femoral marrow status (hazard ratio=11.07). The distant metastases-free survival was significantly reduced in ER negative (P<0.0005), Node-positive (P=0.0215), and clinical stage 3 patients (P=0.0163). On the other hand, a more marked difference was observed in the femoral marrow status (P<0.0001). The hazard ratio for distant metastases was 2.44 in clinical stage, 2.74 in tumor size, 2.74 in Node, and 3.68 in ER, which were each independent prognostic factors associated with distant metastases. However, femoral marrow status was markedly associated with distant metastases (hazard ratio=5.27). CONCLUSIONS: Bone marrow accumulation of Tc-99m tetrofosmin can be a promising prognostic factor independent of conventional prognostic factors for predicting development of not only bone metastases but also distant metastases in breast cancer.     

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     

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.     

Noninvasive staging of lung cancer. Indications and limitations of gallium-67 citrate imaging

The results of evaluation of the hila and mediastinum with 67Ga scans are contradictory, as are the recommendations by different investigators on the use of 67Ga scintigraphy in the clinical evaluation of patients with primary lung carcinoma. Nevertheless, the economy and logistic simplicity of evaluating local and distant metastases with a single imaging procedure are attractive, especially because the symptoms may not enable the physician to make a correct identification of the organ systems affected by metastases. Neumann and Hoffer state that "at present conventional Ga-67 scanning techniques cannot be recommended for preoperative staging of mediastinal lymph node metastases in lung cancer patients." According to Waxman, 67Ga scintigraphy, relative to other imaging modalities, is a sensitive indicator of hilar spread of a tumor. However, because of the normally high background activity within the sternum and spine, mediastinal abnormalities may be poorly detected. Since most pulmonary tumors metastasize via regional nodes to the pulmonary hilum and then to the mediastinum, the high sensitivity for the detection of pulmonary hilar abnormalities and the high specificity for detection of mediastinal lesions suggest that gallium scintigraphy is a valuable adjunctive test when used appropriately. The results obtained locally are probably the best guide for individual physicians in the selection of diagnostic tests for their patients. Gallium scans may thus be helpful in the clinical evaluation of patients with lung cancer. Although gallium scans identify mediastinal node involvement, there is considerable controversy over the relationship between the sensitivity and specificity of the method. By detecting distant extrathoracic metastases, the 67Ga scan may identify a small group of patients who can be spared a needless operation. Gallium scanning fails specifically for metastases within the brain; thus, it does not supplant CT scans of the brain and it is less sensitive than bone scans in detecting osseous metastases. Gallium scanning of patients with small-cell lung cancer is not useful in the selection of therapy but does become important from a prognostic standpoint. Patients with extrathoracic involvement by small-cell carcinoma of the lung are known to have limited survival times compared with those of patients with thoracic involvement alone. In identifying patients with extensive disease, the oncologist is thus provided with prognostic information that may be useful in the counseling of the patient and the patient's family.     

Rationale for the use of bone scans in selected metastatic and primary bone tumors

Since the introduction of bone scans in 1951, there have been many studies comparing biologic and physical characteristics of new bone-imaging agents and the results of scintigraphy and radiology in large numbers of patients. Relatively speaking, there have been fewer studies detailing the health benefits and financial cost associated with the use of skeletal scintigraphy. This review concerns these aspects in patients with malignancies of various sites and stages. About 2% of patients with stage I or II breast cancer have bone metastases at the time they first present, whereas nearly 28% of patients with stage III disease have bone metastases. A large percentage of patients with initially negative scans develop bone metastases during the first 3--4 yr; many of them develop them within the first 12--18 mo after initial diagnosis. For patients with lung cancer, the use of bone scans in staging their disease is somewhat controversial. Several studies indicate that the yield of positive bone scans may range from as low as 2% to as high as 35%. Data on the use of bone scans in staging prostatic cancer initially are similar to those in patients with breast cancer, that is, yields of 7% in patients with stage I or II disease and a yield of about 20% with stage III disease. Children with osteosarcoma or Ewing's sarcoma rarely have bone disease distant from the site of their primary bone lesion at presentation. However, a large percentage of them (30%--40% or so) develop bone metastases during the follow-up period. As in the case with patients with breast cancer, about half of these bone metastases are evident by 12--18 mo.     

Leuprolide therapy for prostate cancer. An association with scintigraphic "flare" on bone scan

The scintigraphic "flare" phenomenon on bone imaging refers to an increase in intensity of tracer uptake in sites of bone metastases and/or the appearance of "new" lesions, which occur shortly after commencement of hormonal therapy or chemotherapy for breast, prostate, or lung cancer. In this study, we observed that scintigraphic flare can occur in patients with prostate cancer following treatment with the "hormone-like" luteinizing hormone releasing hormone analog, leuprolide acetate. Twenty-six patients with prostate cancer being treated with leuprolide acetate underwent serial bone scans at three-month intervals. Five (19.2%) of the 26 patients had findings consistent with a scintigraphic flare on bone scans obtained between three and six months after initiation of therapy. These scan findings should not be confused with progression of skeletal metastases.     

A correlation study of bone scanning with clinical and laboratory findings in the staging of nonsmall-cell lung cancer.

Fifty consecutive patients who had a bone scan and a diagnosis of nonsmall-cell lung carcinoma were studied, retrospectively, to determine the usefulness of bone scans in the presurgical workup. Bone scans were interpreted as positive for bone metastases if the scanning abnormality could not be explained by other causes (e.g., trauma or arthritis) or by additional studies (e.g., radiography or CT scanning). Seventeen percent of the patients whose initial clinical and laboratory findings suggested only localized resectable tumor had positive bone scans, changing treatment from surgery to more conservative therapy. Thirty-six percent of patients with no evidence of lung cancer extending to the mediastinum or beyond by CT of the chest and upper abdomen had bone scans indicating bone metastases (positive bone scan). These results suggest that bone scan adds useful information to the presurgical evaluation of patients with nonsmall-cell lung cancer. Clinical findings and/or CT of the chest and upper abdomen are not sensitive or specific enough to exclude bone metastases. Bone scan is recommended before thoracotomy for patients considered for surgery for localized, potentially resectable nonsmall-cell lung cancer.     

Abdominal CT in the staging of small-cell carcinoma of the lung: incidence of metastases and effect on prognosis

CT studies of the abdomen performed on 72 patients with small-cell carcinoma of the lung were retrospectively reviewed to assess the role of abdominal CT in staging. Forty-four of the 72 patients had extensive disease, defined as disease extending beyond the confines of one hemithorax, plus or minus mediastinal or ipsilateral supraclavicular disease or ipsilateral pleural effusion. Initial-staging abdominal CT revealed one or more sites of metastatic disease in 26 (59%) of these 44 patients, while 18 patients had normal initial CT examinations. Statistical analysis of patients with extensive disease revealed a significant increase in complete therapeutic response (p = .0054) and in the length of survival (p = .001) among those who had extensive disease without abdominal metastases as compared with those who had abdominal metastases on their initial abdominal CT examination. The development of new or recurrent abdominal metastases in general or in specific organs on follow-up scans obtained in 35 patients did not significantly decrease their survival time as compared with that of patients without such metastases. Our findings suggest that CT of the abdomen is beneficial in the initial staging of patients with small-cell carcinoma of the lung and provides prognostic information concerning response to therapy and length of survival.     

CT-Guided Radiofrequency Ablation in Patients with Hepatic Metastases from Breast Cancer

The purpose of this study was to evaluate technical success, technique effectiveness, and survival following radiofrequency ablation for breast cancer liver metastases and to determine prognostic factors. Forty-three patients with 111 breast cancer liver metastases underwent CT-guided percutaneous radiofrequency (RF) ablation. Technical success and technique effectiveness was evaluated by performing serial CT scans. We assessed the prognostic value of hormone receptor status, overexpression of human epidermal growth factor receptor 2 (HER2), and presence of extrahepatic tumor spread. Survival rates were calculated using the Kaplan–Meier method. Technical success was achieved in 107 metastases (96%). Primary technique effectiveness was 96%. During follow-up local tumor progression was observed in 15 metastases, representing a secondary technique effectiveness of 86.5%. The overall time to progression to the liver was 10.5 months. The estimated overall median survival was 58.6 months. There was no significant difference in terms of survival probability with respect to hormone receptor status, HER2 overexpression, and presence of isolated bone metastases. Survival was significantly lower among patients with extrahepatic disease, with the exception of skeletal metastases. We conclude that CT-guided RF ablation of liver metastases from breast cancer can be performed with a high degree of technical success and technique effectiveness, providing promising survival rates in patients with no visceral extrahepatic disease. Solitary bone metastases did not negatively affect survival probability after RF ablation. Drs. Jakobs and Hoffmann contributed equally to this article.     

Comparison of FDG-PET and Bone Scans for Detecting Skeletal Metastases in Patients with Non-small Cell Lung Cancer

Purpose: Positron Emission Tomography (PET) with F18-fluorodeoxyglucose has been proven useful for staging non-small cell lung cancer. Bone scans are frequently performed for suspected skeletal metastases. The purpose of this study was to evaluate if bone scans compared to PET scans provide additional information that changes the stage of disease.Procedures: Nineteen patients with non-small cell lung cancer had PET and bone scans done for staging of the malignancy. The results of both studies were compared.Results: Bone and PET scans agreed on the presence or absence of skeletal metastases in all nineteen patients. The addition of a bone scan to a PET scan did not change the stage of the disease or the management in any of the patients. Bone scans allowed for more precise localization of the lesions in some patients.Conclusions: Bone scans do not change the stage of disease when performed in addition to PET scans, but provide more precise localization of skeletal abnormalities.     

Comparative value of bone scintigraphy and radiography in monitoring tumor response in systemically treated prostatic carcinoma

Radionuclide bone scans and skeletal radiographs were obtained before and during combination chemotherapy or initial hormonal treatment in 46 patients with disseminated adenocarcinoma of the prostate. The purpose of the study was to determine the usefulness of these two modalities in evaluating tumor response to therapy. Prior to treatment, bone scans were positive in 44 patients (96%). In all but one patient either bone radiographs or bone marrow biopsy revealed evidence of osseous metastases. In 22 patients partial response to therapy was documented by a variety of other staging tests. Eleven of these patients showed concurrent or later improvement on bone scans; one showed improvement on a radiograph. "Flare phenomena" were observed relatively frequently since 23% of the scans and 50% of the radiographs showed worsening at the time of response. Bone scans revealed worsening in 79% of 33 patients with disease progression of extraosseous tumor; radiographs were equally sensitive (82% worsening). It is concluded that bone scans in particular are useful for monitoring tumor status in systemically treated patients with prostate cancer. However, because of the lack of sensitivity for response and paradoxical worsening with tumor regression in some patients, scans are not accurate enough to be employed as the sole test in following these patients.     

Radionuclide evaluation of skeletal metastases: Practical considerations

The indications for radionuclide bone scanning to evaluate possible metastatic disease are reviewed. The causes of false-positive and falsenegative interpretations are discussed and illustrated. Since breast cancer leads all malignant tumors in incidence of skeletal metastases found at autopsy, the efficacy of preoperative bone scans in patients with breast cancer is analyzed in detail. A routine preoperative bone scan for patients with Stage I breast cancer produces negligible immediate benefits, but may serve a useful purpose as a baseline to enhance the detection of subtle changes that could represent metastases in a subsequent scan. However, the clinical usefulness of this screening procedure for Stage I disease must be balanced with its cost. Clinical Stage II is a grey area and may include patients with large primary tumors and axillary nodal involvement, implying a greater chance for the occurrence of skeletal metastases and hence a significant yield in bone scans. Patients with clinical Stages III or IV disease have the greatest chance of harboring metastases and should have an extensive diagnostic evaluation including bone scans prior to definitive treatment. Selected radiographs of sites of abnormally increased radionuclide activity and an anteroposterior radiograph of the pelvis should be correlated with the scan to permit a single comprehensive diagnostic impression.Presented at the 11th Annual Meeting and Refresher Course of the International Skeletal Society, Philadelphia, Pennsylvania, USA, September 12–15, 1984     

Detection of occult bone metastases of lung cancer with fluorine-18 fluorodeoxyglucose positron emission tomography

Accurate staging of cancer has a critical role in optimal patient management. Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET) is superior to CT in the detection of local and distant metastases in patients with non-small cell lung cancer. Although Tc-99 m methylene diphosphonate (MDP) bone scanning is well established in the evaluation of bone metastases, there are conflicting reports on the use of FDG PET in the evaluation of skeletal metastases. We report on a patient with locally advanced lung carcinoma in whom FDG PET accurately identified previously unsuspected widespread asymptomatic bone metastases (bone scan and X-rays negative, confirmed on MRI). Assessment of glucose metabolism with FDG PET might represent a more powerful tool to detect bone metastases in lung cancer compared with conventional bone scans.     

Staging bone scintigraphy in nasopharyngeal carcinoma

Bone scintigraphy was performed on 163 new cases of nasopharyngeal carcinoma without clinical evidence of distant metastases. Among the 10 abnormal bone scans one patient had radiographic skeletal metastases corresponding to the areas of increased tracer uptake. Two patients with abnormal bone scans subsequently developed radiographic metastases at the site of abnormal tracer uptake. The detection rate of asymptomatic skeletal metastases on presentation was thus 1.8% (3/163), and the predictive value of an abnormal scan for metastases 30% (3/10). Bone scintigraphy is not justified as a routine staging investigation for nasopharyngeal carcinoma, although it can be considered for a subset of patients considered at high risk of distant metastases.     

Value of FDG PET in papillary thyroid carcinoma with negative 131I whole-body scan.

The management of metastatic thyroid carcinoma patients with a negative 131I scan presents considerable problems. Fifty-four athyrotic papillary thyroid carcinoma patients whose 1311 whole-body scans were negative underwent 18F-fluorodeoxyglucose (FDG) PET; the purpose was to determine whether this procedure could localize metastatic sites. We also assessed its usefulness in the management of these patients. METHODS: Whole-body emission scan was performed 60 min after the injection of 370-555 MBq 18F-FDG, and additional regional attenuation-corrected scans were obtained. Metastasis was pathologically confirmed in 12 patients and was confirmed in other patients by overall clinical evaluation of the findings of other imaging studies and of the subsequent clinical course. RESULTS: In 33 patients, tumor had metastasized, whereas 21 patients were in remission. FDG PET revealed metastases in 31 patients (sensitivity 93.9%), whereas thyroglobulin levels were elevated in 18 patients (sensitivity 54.5%). FDG PET was positive in 14 of 15 metastatic cancer patients with normal thyroglobulin levels. In 20 of 21 patients in remission, FDG PET was negative (specificity 95.2%), whereas thyroglobulin levels were normal in 16 patients (specificity 76.1%). The sensitivity and specificity of FDG PET were significantly higher than those of serum thyroglobulin. In patients with negative 1311 scans, FDG PET detected cervical lymph node metastasis in 87.9%, lung metastasis in 27.3%, mediastinal metastasis in 33.3% and bone metastasis in 9.1%. In contrast, among 117 patients with 131I scan-positive functional metastases, 131I scan detected cervical lymph node metastasis in 61.5%, lung metastasis in 56.4%, mediastinal metastasis in 22.2% and bone metastasis in 16.2%. In all 5 patients in whom thyroglobulin was false-negative with negative antithyroglobulin antibody, PET showed increased 18F-FDG uptake in cervical lymph nodes, mediastinal lymph nodes, or both. Among patients with increased 18F-FDG uptake only in the cervical lymph nodes, the nodes were dissected in 11. Metastasis was confirmed in all, even in normal-sized lymph nodes. CONCLUSION: FDG PET scan localized metastatic sites in 131I scan-negative thyroid carcinoma patients with high accuracy. In particular, it was superior to 131I whole-body scan and serum thyroglobulin measurement for detecting metastases to cervical lymph nodes. FDG PET was helpful for determining the surgical management of these patients.     

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.     

Visualization of metastatic liver disease on technetium-99m bone scintigraphy

To determine the frequency with which liver metastases are visualized on bone scintigraphy, 425 pairs of liver and bone scans, performed within one month of each other, were reviewed. Sixty-three of the 425 liver scans showed metastases. Of these 63, five cases of carcinoma of the colon and six cases of carcinoma of the lung also visualized by Tc-99m MDP scintigraphy. This represented 46% of colon metastases and 15% of lung metastases detected on liver scan. Liver metastases from other primary tumors were not detected on bone scan, but the numbers for these tumors were small. The liver metastases which were detected on bone scan were significantly larger than those which were not. The literature was reviewed and the primary and secondary tumors of liver with uptake of Tc-99m phosphate compounds listed.     

Limited value of CT brain scans in the staging of small cell lung cancer

Computed tomography of the brain was performed as part of the initial staging evaluation of 84 patients with small cell lung cancer. Brain scans indicative of metastatic disease were obtained in 12 (14%) patients, two of whom had no neurologic signs or symptoms. One of these had no other extrathoracic disease. Brain scans without evidence of metastatic disease were obtained in 72 patients, 58 (80.5%) of whom had no signs or symptoms suggestive of metastatic intracranial disease. In the 14 patients with neurologic symptoms but negative computed tomographic scans, other explanations than brain metastases were found. It was concluded that head scanning is a sensitive and accurate method of detecting central nervous system metastases in patients with small cell lung cancer. However, head computed tomography should not be included as part of the initial staging evaluation of the neurologically asymptomatic patients. In only one of 60 such patients did the brain scan change the initial clinical staging, which included chest films, liver and bone scans, and bone marrow biopsy.