Routine bone scans in patients with prostate cancer related to serum prostate-specific antigen and alkaline phosphatase

OBJECTIVE: To evaluate the need for a bone scan as a routine staging procedure in patients with newly diagnosed prostate cancer in relation to serum prostate-specific antigen (PSA) and alkaline phosphatase (ALP) levels, and thus determine whether a reduction of the use of this staging method is possible in patients with a low probability of osseous metastasis. PATIENTS AND METHODS: The results of bone scans were related retrospectively to levels of serum PSA and ALP in 363 patients with prostate cancer newly diagnosed between 1989 and 1997. RESULTS: Of 363 consecutive patients, 111 had a positive bone scan. In 19 of 144 (13%, "missed diagnosis") patients with a PSA level of < 20 ng/mL the bone scan was positive. In 125 patients (49%, "false-positives") with a PSA level of > 20 ng/mL the bone scan was negative. A threshold level of 100 U/L for ALP gave a better balance for the number of "false-positives" and "missed diagnosis". ALP values correlated better with an abnormal bone scan than did PSA levels; ALP levels of > 90 U/L indicated a 60% chance for the presence of bone metastases. CONCLUSION: Patients with newly diagnosed and untreated prostate cancer should undergo bone scintigraphy if there is bone pain or if ALP levels are > 90 U/L. Recent reports discourage the routine use of a bone scan when the serum PSA level is <20 ng/mL. However, the present series suggests there is a greater chance of a positive bone scan in patients with low PSA levels; these findings need further confirmation.     

The positive yield of imaging studies in the evaluation of men with newly diagnosed prostate cancer: a population based analysis

PURPOSE: We determine the positive yield of imaging studies performed on men with newly diagnosed prostate cancer. MATERIALS AND METHODS: A prospective, population based survey was conducted on 3,690 men with prostate cancer diagnosed between October 1, 1994 and October 31, 1995. Cases were identified by the rapid case ascertainment systems used in 6 geographic regions participating in the Surveillance, Epidemiology and End Results Program. Based on information captured in primary medical record reviews we estimated the positive yield of bone scans, computerized tomography (CT) and magnetic resonance imaging. RESULTS: The positive yield of bone scan and CT was less than 5% and 12%, respectively, for all men with prostate specific antigen (PSA) 4 to 20 ng./ml., and less than 2% and 9%, respectively, for those who also had a Gleason score of 6 or less. Only men with PSA greater than 50 ng./ml. and those with Gleason scores 8 to 10 and PSA greater than 20 ng./ml. had positive yields greater than 10% and 20% for bone scan and CT, respectively. CONCLUSIONS: Imaging studies designed to identify metastases and/or extracapsular extension in men with newly diagnosed prostate cancer frequently have a low positive yield. Wide variations exist in the use of imaging studies and are associated with tumor factors, such as Gleason score and serum PSA, and nontumor factors, such as state of residence. More extensive cost-effectiveness analyses are needed to define appropriate guidelines for ordering imaging studies to optimize the positive yield among men with newly diagnosed prostate cancer.     

Radionuclide bone scintigraphy in patients with biochemical recurrence after radical prostatectomy: when is it indicated?

OBJECTIVE: To evaluate the use of radionuclide bone scintigraphy following biochemical recurrence after radical retropubic prostatectomy (RRP) for localized prostate cancer. PATIENTS AND METHODS: Of 1197 patients undergoing RRP we identified those with biochemical recurrence and who had also had a bone scan. Biochemical recurrence was defined as a prostate specific antigen (PSA) level of > or = 0.4 ng/mL. Patients with indeterminate bone scan findings and those in whom the interval between the PSA test and the bone scan was >3 months were excluded. Patient age, PSA level and other relevant pathological details were recorded. Clinical symptoms at the time of bone scan, androgen deprivation after RRP, bone scintigram details and time to recurrence were documented. RESULTS: Of the 1197 patients, 153 (12.8%) had a biochemical recurrence and 35 (23%) of these had a total of 44 bone scans taken over a mean (sd) follow-up of 70.4 (35.6) months; 34 (77%) bone scans were negative (group 1) and 10 (33%) positive (group 2). In group 1 the mean PSA at the bone scan was 5.2 ng/mL; 76% of the patients had a PSA of < 7 ng/mL. In group 2 the mean PSA at the bone scan was 30.7 ng/mL and all patients had a PSA of >7 ng/mL. The only significant difference between the groups was the PSA at the time of the bone scan (P < 0.001). CONCLUSION: Bone scintigraphy is a sensitive diagnostic tool for detecting prostate cancer metastases to bone. A bone scan in patients with a serum PSA of <7 ng/mL on biochemical recurrence after RRP is unlikely to be positive, whereas a PSA of > or = 20 ng/mL is. The presence of skeletal symptoms or a PSA level of >7 ng/mL should prompt the clinician to obtain a bone scintigram.     

Radionuclide bone scan in patients with newly diagnosed prostate cancer. Clinical aspects and cost analysis

BACKGROUND: The indication for a radionuclide bone scan in patients with newly diagnosed, untreated prostate cancer remains controversial. PATIENTS AND METHODS: In this retrospective study we examined 406 patients who had received a staging bone scan irrespective of their PSA serum level and histology. We evaluated different guidelines and recommendations with respect to their usefulness. The costs were calculated according to EBM and GOA. We evaluated the classification systems of bone metastases according to Soloway, Crawford, and Rigaud. RESULTS: The bone scan was positive in 41 (10%) of 406 patients. The EAU guidelines turned out to be useful with respect to both clinical value and cost efficiency. The Rigaud classification of bone metastases predicted outcome better than the Soloway or Crawford classification. CONCLUSIONS: The EAU guidelines from 2005 are a useful tool to decide whether to perform a bone scan in patients with newly diagnosed, untreated prostate cancer. A bone scan should be performed if PSA levels exceed 20 ng/ml in patients with a G1/G2 histology, and in patients with G3 histology and locally advanced disease irrespective of PSA level. Bone scan metastases should be classified according to Rigaud.     

Prostate specific antigen and bone scan correlation in the staging and monitoring of patients with prostatic cancer.

The ability of serum prostate specific antigen (PSA) to predict bone metastases at initial presentation was determined in 146 patients, and in 66 patients during a 3-year period; 14.7% of patients with bone metastases at presentation had a PSA value less than 20 ng/ml. All patients who subsequently developed bone metastases had a PSA greater than 20 ng/ml and the rise in PSA often antedated the detection of bone metastases. Bone scans are still necessary in the initial staging but following diagnosis and treatment can be replaced by serum PSA measurement in monitoring patients with prostatic cancer.     

The criteria for avoiding unnecessary computerized tomography and bone scan in staging patients with newly diagnosed prostate cancer: retrospective study of patients at Matsusaka Chuo General Hospital

PURPOSE: Staging for prostate cancer often includes computed tomography (CT) and bone scan in Japan. We examined the criteria of avoiding unnecessary CT and bone scan for the prostate cancer patients at Matsusaka Chuo General Hospital. SUBJECTS AND METHODS: 211 patients were newly diagnosed at our institution between 1998 September and 2004 April. We reviewed data from 208 patients who had a staging CT and bone scan. The data was analysed using Gleason score, clinical T-stage and serum prostatic specific antigen (PSA) level. RESULTS: CT detected lymphadenopathy in 19 patients (9.1%), Bone scan detected bone metastasis in 31 patients (14.9%). However there was no lymphadenopathy detected by CT in the patients with 20 ng/ml or less. In the analysis using PSA and Gleason score, there was no bone metastasis detected by bone scan in the patients with PSA level of 20 ng/ml or less and Gleason sum 7 or less. In the analysis using PSA and clinical local stage there was no bone metastasis detected by bone scan in the patients with PSA level of 20 ng/ml or less and localized lesion (cT1-2). CONCLUSION: In a new proatate cancer patient CT and bone scan can be avoidable by PSA level of 20 ng/ml or less and cT1-2 or less and Gleason sum 7 or less.     

Multiple myeloma diagnosed during hormonal therapy for prostate cancer: report of two cases

Case 1: A 73-year-old man presented with a serum prostate specific antigen (PSA) level of 30.2 ng/ml, and was diagnosed with prostate cancer (cT3aN0M1, stageD2), for which hormonal therapy (maximal androgen blockade : MAB) was commenced. Nine months later he developed back pain, and osteolytic bone lesions progressed despite a stable, low PSA level (0.087 ng/ml). He was diagnosed with multiple myeloma on the basis of positive M protein on immunoelectrophoresis. MP combination therapy (melphalan and prednisolone) was commenced, but the patient died of multiple myeloma 33 months later. Case 2: A 70-year-old man was diagnosed with prostate cancer (PSA 19 ng/ml) at another hospital 5 years ago, and underwent hormonal therapy (luteinizing hormone-releasing hormone (LHRH) agonist only). He was referred to our hospital and underwent bicalutamide+MAB combination therapy due to a raised PSA level (58 ng/ml) and multiple bone metastases. His PSA level dropped to around 20 ng/ml, but 2 years later he developed back pain, and bone metastases with osteolytic change were seen in the skull, ribs, and limbs. Needle aspiration biopsy of a fist-sized soft tissue mass in the chest wall showed multiple myeloma. Although chemotherapy with melphalan was commenced, the patient died of multiple myeloma 8 months after its diagnosis. Both these cases exhibited rapidly progressing bone lesions, regardless of an absence of any large fluctuations in serum PSA levels, during hormonal therapy for prostate cancer. Further investigations yielded the diagnosis of multiple myeloma. If progression of bone lesions does not match the status of prostate cancer as surmised from the serum PSA level, we should consider the possibility of multiple myeloma, and biopsy of one of the bone lesions.     

Bone scan findings in a North African ethnic group and relation to PSA level and Gleason score of the biopsy

ObjectiveA number of large-scaled studies carried out in western countries have proven a positive relationship between serum prostate specific antigen (PSA) level and prevalence of positive bone scan findings, in newly diagnosed prostate cancer patients. The aim of our study is to verify that the tendency occurs as well in north-african population, as well as to establish a possible correlation between PSA level, bone scan result, and Gleason score.Material and methodsRecords of 348 patients diagnosed to have prostatic adenocarcinoma were reviewed retrospectively for bone scan results, PSA levels, and Gleason score. Statistical analyses were performed using the Fisher exact test, by a statistical software (statistical package for the social sciences “SPSS”, version 11.5.1, Chicago, IL) with differences at P < 0,05 considered significant.ResultsBased on positive bone scintigraphy 102 patients were proven to have bone metastases. None of these patients had a PSA level of less than 10 ng/ml. Six metastatic patients had PSA level between 11 and 20 ng/ml. 45 metastatic cases had serum PSA between 21 and 100. Concerning PSA level over 101 ng/ml, 51 men had positive bone scan.ConclusionBased on the PSA level, the likelihood of positive bone scan result can be postulated. According to PSA levels, staging investigations can be more selective for our patients. The risk of positive bone scan is so low that it is not required for patients with PSA level less than 10 ng/ml. On the other hand, on studying the correlation between Gleason score and PSA level or bone scan results, no statistically significant relationship was established.     

Influence of local tumour stage and grade on reliability of serum prostate-specific antigen in predicting skeletal metastases in patients with adenocarcinoma of the prostate

OBJECTIVE: To determine whether serum prostate-specific antigen (PSA) can be reliably used to predict the absence or presence of skeletal metastases on the bone scan in patients with adenocarcinoma of the prostate. METHODS: We studied 450 consecutive men presenting with adenocarcinoma of the prostate between 1991 and 1995. Serum PSA was measured by the Hybritech Tandem-R monoclonal immunoradiometric assay and bone scanning was performed with 99m-technetium-labelled methylene diphosphonate. In total, 46 patients were excluded for one or more of the following reasons: serum PSA not available; radionuclide bone scan inconclusive; histology of the prostate other than adenocarcinoma; hormonal or other therapy given prior to obtaining the serum PSA and/or bone scan. RESULTS: Of the 404 patients included, 43% had poorly differentiated (grade 3), 74% had locally advanced (stages T3-4) tumours and 50% had skeletal metastases. The mean and median serum PSA were 348 and 52 ng/ml, respectively, and 77% of the patients had a serum PSA >20 ng/ml. The negative predictive value (for the absence of metastases on bone scan) of a serum PSA <20 ng/ml was 87% for the whole group of patients, 92, 94 and 70% for grade 1, 2 and 3 tumours, and 95, 83 and 50% for stage T1-2, T3 and T4 tumours, respectively. The positive predictive value (for the presence of metastases on bone scan) of a serum PSA >100 ng/ml was 80% for the whole group of patients. CONCLUSIONS: In patients presenting with adenocarcinoma of the prostate, serum PSA alone is not sufficiently reliable to predict the absence or presence of metastases on the radionuclide bone scan. In patients with grade 3 and clinical stage T3-4 tumours, a bone scan should be obtained for accurate staging, regardless of the serum PSA value.     

Small cell carcinoma of the prostate: a case report

A 76-year-old man had been treated with maximum androgen blockade therapy for a poorly-differentiated prostate adenocarcinoma (T3cN1M0, prostate specific antigen (PSA) 65 ng/ml, Gleason Score 4+5=9) since September 2002. By August 2003, his serum PSA levels were undetectable and the lymph node swelling had vanished. However, in December 2004, his serum PSA levels started rising gradually up to 0.66 ng/ml. Radiation therapy on the prostate was then performed (66 Gy). At that time, no metastasis was detected by computed tomography and bone scintigraphy. In August 2005, multiple bone metastases were detected. Immunohistochemical examination of a biopsy specimen from the bone lesion revealed a small cell carcinoma/neuroendocrine cell carcinoma. He died with undetectable PSA levels (less than 0.008 ng/ml) in December 2005. The autopsy showed multiple organ metastases including bone, liver, lungs and others. The immunohistochemical examination revealed pure small cell carcinoma in all metastatic lesions. A precise histological examination of the lungs using a 1 cm serial section could not reveal any tumors compatible with primary lung cancer. We concluded from the clinical history and autopsy findings that his initial poorly-differentiated adenocarcinoma of the prostate dedifferentiated into a pure small cell carcinoma with neuroendocrine differentiation.     

血清PSA值和前列腺结节指导前列腺穿刺活检的临床意义

目的 探讨血清ＰＳＡ浓度变化与前列腺癌及其骨转移的相关性。方法 对９３例直肠指诊异常及血清ＰＳＡ〉４ｎｇ／ｍｌ的患者,行直脾性Ｂ超引志下前列腺穿刺活检;用９９ｍＴｃ－ＭＤＰ行全身骨扫描判断有无骨。结果 ９３例中前列腺活检阳性者６０例,其中２６例扫描阳性;随血清ＰＳＡ浓度升高,前列腺阳性活检率及其远处骨转移阳性率升高。 血清ＰＳＡ升高与前列腺癌及其骨转移的发生率呈正相关。     

The Value of Serum Prostate Specific Antigen and other Parameters in Detecting Bone Metastases in Prostate Cancer

The cut-off value of serum prostate-specific antigen (PSA) level in prediction of bone metastases and the correlation of serum PSA with the clinical stage, grade, score and the rate of bone metastases have been investigated in cases of prostate cancer (PCa).The study population consisted of 160 patients with histologically proven PCa between April, 1993 and August, 1996. The negative predictive value and the sensitivity were the highest (94%) in patients with a serum PSA value less than 10 ng/ml.We claim that in patients with PSA values less than 10 ng/ml whole body bone scan is not necessary.     

Predicting radionuclide bone scan findings in patients with newly diagnosed, untreated prostate cancer: prostate specific antigen is superior to all other clinical parameters.

Presently, the standard staging evaluation of prostate cancer includes digital rectal examination, measurement of serum tumor markers and a radionuclide bone scan. To evaluate the ability of local clinical stage, tumor grade, serum acid phosphatase, serum prostatic acid phosphatase (PAP) and serum prostate specific antigen (PSA) to predict bone scan findings, a retrospective review of 521 randomly chosen patients (mean age 70 years, range 44 to 92 years) with newly diagnosed, untreated prostate cancer was performed. Local clinical stage, tumor grade, acid phosphatase, PAP and PSA all correlated positively with bone scan findings (p less than 0.0001). Using receiver operating characteristic curves, however, PSA had the best over-all correlation with bone scan results. The median serum PSA concentration in patients with a positive bone scan was 158.0 ng./ml., whereas men with a negative bone scan had a median serum PSA level of 11.3 ng./ml. (p less than 0.0001). Using multivariate logistic regression analysis, local clinical stage, tumor grade, acid phosphatase and PAP were evaluated in combination with PSA to assess whether these parameters increased the ability of PSA alone to predict bone scan findings. None of these clinical parameters, irrespective of the combination used, contributed appreciably to the predictive power of PSA alone. A probability plot with 95% confidence intervals was constructed that allows the practicing urologist to estimate on an individual basis the probability of a positive bone scan for any given serum PSA value. The most significant finding of this study, however, was the negative predictive value of a low serum PSA concentration for bone scan findings. In 306 men with a serum PSA level of 20 ng./ml. or less only 1 (PSA 18.2 ng./ml.) had a positive bone scan (negative predictive value 99.7%). This finding would suggest that a staging radionuclide bone scan in a previously untreated prostate cancer patient with a low serum PSA concentration may not be necessary.     

A study on staging bone scans in newly diagnosed prostate cancer

OBJECTIVE: This study aimed to evaluate the role of bone scan as a staging investigation in newly diagnosed untreated prostate cancers. MATERIALS AND METHODS: Bone scan results in patients with newly diagnosed prostate cancer were reviewed and correlated with clinical stage, prostate-specific antigen (PSA) and Gleason scores from the biopsy specimen. RESULTS: In all, 124 patients fulfilled inclusion criteria with an age range of 51-94 (mean 72.3) years. Pre-biopsy PSA ranged from 2.2 to 5,864 with a median of 21.1 ng/ml. Clinical stage was T0-T1c 14.5%, T2a 41.9%, T2b 17.7%, T3 16.9%, and T4 9%. A Gleason score of 7 was found in 31%. Four patients' samples were not suitable for Gleason scoring. Twenty patients (16.1%) had a positive bone scan with a mean age of 79.4 years (median 83). Two patients with PSA<20 ng/ml were positive. Of the 44 scans performed in the patients with PSA相似文献   

PSA和SPECT骨显像在前列腺癌诊断治疗中的意义

目的：研究PSA、SPECT骨显像在前列腺癌诊断及治疗中的临床意义。方法：对100例经临床确诊的前列腺癌患者全部行血清PSA测定及全身骨显像。结果：发生骨转移的患者为81％,PSA≥20tμg／I．的患者发生骨转移的为60％。结论：血清PSA与骨显像联检对前列腺癌临床诊断、疗效观察及预后判定具有重要的指导意义。     

Detection of occult micrometastases in the bone marrow of patients with prostate carcinoma

A panel of three monoclonal antibodies that recognize membrane and cytoskeletal antigens expressed by epithelial cells (T₁₆′ C₂₆′ and AE-1) was used in a sensitive immunohistochemical assay to detect tumor cells in bone marrow aspirates from 20 patients with prostate cancer. Bone marrow aspirates from 2/9 (22%) patients with localized prostate cancer (stage B, 0/5; Stage C, 2/4), and 4/11 (36%) patients with metastatic prostate cancer (Stage D₁′ 0/7 patients; Stage D₂′ 4/4 patients) had antigen-positive cells in their bone marrow. The patients with localized disease had conventional examinations for metastases, including radioisotope bone scans and examination of bone marrow cytology, which were negative. The serum prostatic specific antigen (PSA) level appeared to correlate with the presence of micrometastases. Those patients with localized disease and antigen-positive cells in the bone marrow had an average serum PSA level of 26.6 ng/ml, while the average serum PSA level in patients without antigen-positive cells was 12.3 ng/ml. In addition, the number of antigen-positive cells detected appeared to correlate with the stage of disease; patients with Stage C prostate cancer had an average of 10 antigen-positive cells per one million bone marrow elements, while patients with Stage D2 disease had an average of 25 antigen-positive cells per one million bone marrow elements. We have demonstrated that immunohistochemical staining of bone marrow aspirates can detect occult bone marrow metastases in patients with apparently localized prostate cancer. Further follow-up of these and a larger number of patients will be required to determine the potential clinical significance of this finding. © 1994 Wiley-Liss, Inc.     

Serum osteoprotegerin (OPG) levels are associated with disease progression and response to androgen ablation in patients with prostate cancer

BACKGROUND: Osteoprotegerin (OPG) is a tumour and/or bone derived factor that may protect tumour cells from apoptosis. In this study, we have measured serum OPG levels in untreated prostate cancer patients with advanced prostate cancer compared to patients with organ confined disease and in treated patients receiving androgen ablation. METHODS: Serum OPG levels were measured by ELISA in samples collected from 104 patients with either newly diagnosed (n = 59) or advanced prostate cancer treated by androgen ablation (n = 45) and compared with levels in serum from patients with benign prostatic hyperplasia (BPH) (n = 10) and young healthy men (n = 10). RESULTS: Untreated patients with locally advanced disease had significantly higher OPG levels than those with organ confined disease. Patients with advanced disease responding to androgen ablation (serum PSA < 1 ng/ml) had serum OPG levels that were significantly lower than those with clinically progressing disease (PSA > 10 ng/ml). OPG levels in the latter were not significantly different from levels in patients with early signs of biochemical progression (PSA >1 but <10 ng/ml). CONCLUSIONS: OPG is a potential new marker, which is elevated in the serum of patients with advanced prostate cancer and may be an indicator of early disease progression.     

The clinical potential of pretreatment serum testosterone level to improve the efficiency of prostate cancer screening

OBJECTIVES: The aim of the present study was to evaluate the clinical value of the pretreatment serum testosterone (T) level as a potential predictor of prostate cancer risk in screening for prostate cancer. MATERIALS AND METHODS: The subjects were 420 patients suspected of having prostate cancer who underwent prostate biopsy, and whose pretreatment T levels were recorded. We checked for association between the presence of prostate cancer and the following clinical factors: pretreatment serum T level, age, pretreatment prostate-specific antigen (PSA) level, digital rectal examination findings, ratio of free to total PSA, prostate volume, and PSA density (PSAD). RESULTS: Overall, there was no significant difference in mean pretreatment T level between patients diagnosed with cancer (3.9+/-2.4 ng/ml) and patients diagnosed with benign prostate disease (BPD; 3.7+/-1.7 ng/ml); diagnosis was based on prostate biopsy. However, among patients with PSA <10 ng/ml, the pretreatment T level was significantly higher in patients diagnosed with prostate cancer (4.2+/-2.6 ng/ml) than in patients diagnosed with BPD (3.6+/-1.4 ng/ml) (p=0.007); a similar trend was observed among patients with PSAD <0.15 ng/ml/cc. Multivariate analysis indicated that pretreatment T level was an independent significant predictor of positive prostate biopsy (p=0.020). Additionally, the serum T level was significantly lower in patients with a Gleason score >or=7 (3.7+/-2.1 ng/ml) versus a score <7 (4.2+/-1.7 ng/ml) (p=0.030). Also, serum T levels were significantly higher in well-differentiated prostate cancer (4.8+/-2.1 ng/ml) versus moderately differentiated (3.8+/-1.3 ng/ml) or poorly differentiated (3.7+/-1.4 ng/ml) (p<0.01). CONCLUSIONS: Among relatively low-risk patients, serum T level was an independent significant predictor of positive prostate biopsy, suggesting that the efficiency of prostate cancer screening can be improved by including measurement of serum T level.     

Predictive value of prostate-specific antigen, tumour stage and tumour grade for the outcome of bone scintigraphy in patients with newly diagnosed prostate cancer.

OBJECTIVE: In order to evaluate the negative predictive value of a low prostate-specific antigen (PSA) for a positive bone scan, we performed a retrospective study in a patient material from the Umea region in Northern Sweden. We also evaluated whether different tumour grades could influence this predictive value. MATERIAL AND METHODS: Four-hundred-and-forty-six patients of newly diagnosed prostate cancer were reviewed. We analysed different levels of PSA, tumour grade, tumour stage and combinations of these parameters for their use in making a positive bone scintigraphy (BS) prediction. RESULTS: Among 214 patients with PSA <20 ng/ml, 9 showed a positive BS. When tumours of grades 2 and 3 were excluded, the number of positive BS predictions decreased to 6. For 350 of these 446 patients, a classification according to TNM was available; 162 of these 350 had a PSA value <20 ng/ml, and when this group comprised only small and well-differentiated tumours (T1-2, G1), only one of the remaining 81 patients had a positive BS result. CONCLUSIONS: We conclude that in most patients with small and well-differentiated tumours (T1-2, G1) and PSA <20, BS staging need not be carried out.     

Laparoscopic pelvic lymph node dissection allows significantly more accurate staging in "high-risk" prostate cancer compared to MRI or CT

OBJECTIVE: To compare the accuracy of lymph node staging using pelvic MRI or CT to that of laparoscopic pelvic lymph node dissection (LPLND) in prostate cancer patients prior to radical radiotherapy. MATERIAL AND METHODS: A total of 55 consecutive patients at high risk of locally advanced disease [prostate-specific antigen (PSA) > 10 ng/ml, Gleason score 7 or worse on biopsy, normal (99m) Tc bone scan] underwent either a pelvic MRI (n = 42) or CT (n = 13) scan and subsequent LPLND. Preoperative staging was compared to the histology of the lymph node specimens obtained. RESULTS: A total of 20/55 (36.4%) patients had pelvic lymph node metastases confirmed by LPLND. MRI identified three patients (27.3%) with pelvic lymph node metastases and missed eight (72.7%) whilst CT identified none of nine patients with pelvic lymph node metastases. The groups with histologically-positive and -negative nodes had similar mean ages (63 vs 65 years; p = 0.52), Gleason scores (6.8 vs 6.5; p = 0.41) and PSA levels (43.1 vs 31.4 ng/ml; p = 0.56). CONCLUSION: The presence or absence of lymph node metastases has critical implications for the prognosis and treatment of prostate cancer. In this study both MRI and CT missed many cases of lymph node metastases in "high-risk" patients. While a positive scan seems likely to indicate nodal metastases, the low sensitivity in high-risk patients seems unacceptable if treatment decisions are to be based on accurate staging, and LPLND offers an alternative.