Staging Of Prostatic Carcinoma Research Articles

Granulomatous Prostatitis Following Bacillus Calmette-Guerin Immunotherapy of Bladder Cancer

Granulomatous prostatitis is a recognized complication of intravesical bacillus Calmette-Guerin immunotherapy of superficial bladder cancer. Of 32 patients receiving such therapy 13 underwent prostatic core biopsy and/or fine needle aspiration for clinical indications. Prostatic induration or nodularity developed in 12 patients and 1 underwent biopsy for staging of known prostatic carcinoma. Granulomatous prostatitis was found in 100 per cent of those patients who underwent biopsy or aspiration, indicating that the incidence of this finding is at least 41 per cent following bacillus Calmette-Guerin immunotherapy. Acid-fast bacilli were demonstrated within the prostate of 3 patients with granulomatous prostatitis. The mean interval between the initiation of therapy and diagnosis of granulomatous prostatitis was 11.5 months. Bacillus Calmette-Guerin related granulomas of the prostate may be differentiated histologically from nonspecific granulomatous prostatitis, allergic prostatitis and postoperative granulomas. The clinical implications of these findings are discussed. (J. Urol, 140: 751-754, 1988)

Transrectal Ultrasonography as a Follow-up Method in Prostatic Carcinoma After External Beam and Interstitial Radiotherapy

Transrectal ultrasonography and ultrasonometrics were employed for follow-up in a total of 28 prostatic carcinoma patients subjected to external beam or interstitial radiotherapy. These two methods permit more accurate staging of prostatic carcinoma and have also proved to be valuable in the follow-up care of patients suffering from locoregional prostatic carcinoma. Of the 20 patients subjected to external beam radiotherapy four patients initially did not show capsular infiltration, 2B2, 2A2, whereas 16 patients presented with infiltration of the capsule and seminal vesicles. After external beam radiotherapy the ultrasonomorphologic findings of four patients revealed a sharply demarcated capsule and unremarkable seminal vesicles, which indicated tumour regression. Of five patients with infiltration of the pelvic floor and/or seminal vesicles, three showed definite tumour regression, whereas the ultrasonograms of the other two patients demonstrated tumour progression despite radiotherapy. In eight patients the greatest reduction in tumour volume was found one year after interstitial radiotherapy. Only one patient, initially presenting with slight infiltration of the capsule, was shown to have infiltration of the capsule and seminal vesicles after interstitial radiotherapy. At follow-up, evaluation of the echo patterns in these patients was inaccurate on account of the dense echoes reflected by the seeds implanted.

Prostatic Specific Antigen and Prostatic Acid Phosphatase in the Monitoring and Staging of Patients with Prostatic Cancer

Serum prostatic specific antigen and prostatic acid phosphatase levels were measured retrospectively and evaluated in 357 men with benign prostatic hypertrophy and in 209 men with various stages of prostatic carcinoma. Although prostatic specific antigen values were elevated in 21 per cent of the patients with benign prostatic hypertrophy, the elevations usually were low and did not interfere with clinical interpretation. Prostatic specific antigen was elevated in 98 per cent of 86 men with active stage D2 disease; in 22 per cent of the men prostatic specific antigen was the only elevated marker. In contrast, prostatic acid phosphatase was the only elevated marker in 1 per cent of the patients with stage D2 disease and neither marker was elevated in 2 per cent. Among 74 patients in whom prostatic specific antigen and prostatic acid phosphatase determinations were made before radical prostatectomy, prostatic specific antigen was elevated substantially (greater than 10ng. per ml.) in 59 per cent (26 of 44) with extracapsular disease and in only 7 per cent (2 of 30) without extracapsular disease. More importantly, of those 28 patients with substantially elevated prostatic specific antigen levels 26 (93 per cent) had extracapsular disease. Serial serum measurements showed that prostatic specific antigen either reflected or predicted clinical status in more than 97 per cent of the patients. We conclude that prostatic specific antigen is an excellent serum tumor marker for monitoring patients with prostatic carcinoma and that it surpasses prostatic acid phosphatase in this regard. Prostatic specific antigen also may be useful in staging prostatic carcinoma and it may change our attitudes significantly about the therapeutic responses to this cancer.

The accuracy of CT in the staging of carcinoma of the prostate.

Previous studies have reported the accuracy of CT in distinguishing stages of prostatic carcinoma, but they lack uniform surgical proof of histopathologic stage. We evaluated CT scans in 32 patients who underwent radical prostatectomy to assess its role in the preoperative staging of prostatic carcinoma. Two experienced radiologists blindly interpreted CT scans of the pelvis; they looked for evidence of tumor beyond the prostatic capsule and involvement of the seminal vesicles (stage C) or involvement of pelvic lymph nodes (stage D). Sixty-four interpretations in 32 patients yielded a specificity of 75% for predicting stages A or B disease (local disease), a sensitivity of 50% for the prediction of stages C or D, and an overall accuracy of staging of 67%. Interpretation errors were due to an inability to detect lymph node metastases, errors in evaluating the seminal vesicles, and errors in interpreting densities surrounding the prostate gland. Our data suggest that CT should not be used to influence decisions concerning surgical vs nonsurgical treatment in patients with clinically staged local disease and is only useful when unsuspected metastatic nodal disease is detected.

Staging of genitourinary cancers. The role of diagnostic imaging.

Computed tomography (CT) is currently the standard modality for staging of urologic cancer in most institutions. It is used for demonstrating nodal involvement, and for demonstrating invasion of the primary lesion into surrounding fat, muscle, or other tissues or organs. It is also useful for demonstrating hepatic metastases in renal and vesical carcinomas. The problem with computed tomography, however, is that it can only show whether the nodes are large or not; neither can it show the nodal architecture, nor can it detect metastases in normal-sized nodes. Intravesical sonography has been helpful for staging papillary bladder cancer. Transrectal sonography has been somewhat helpful for demonstrating seminal vesicle invasion in patients with prostatic carcinoma. Inferior vena cavography and renal venography can be helpful for demonstrating whether a renal, renal pelvic, or adrenal carcinoma has extended into either vein. Lymphography can show nodal architecture and metastases in normal-sized nodes, and can make possible needle biopsy of abnormal-appearing nodes even if they are normal sized. The examination cannot show very small or microscopic nodal metastases, and it can miss abnormal nodes totally if they have been completely replaced by metastases. It yields false positives when fatty or fibrous infiltration of the nodes has occurred. It is used primarily for staging patients with testis or prostatic carcinoma. Bone scans are essential for staging prostatic carcinoma. Magnetic resonance imaging (MRI) is helpful in some cases of renal cell carcinoma. Multiplanar imaging prevents overstaging. It is also accurate for showing whether the renal vein or inferior vena cava are involved. Enlarged lymph nodes are easily distinguished from vessels. For staging bladder carcinoma involving the fundus or base of the bladder, MRI is better than CT. Microscopic nodal metastases, such as are common in carcinoma of the prostate, currently are not detected by any imaging modality.

Reassessment of creatine kinase BB as a marker for cancer of the prostate, breast, and lung.

We used an enzyme-linked immunoabsorbent assay to measure creatine kinase (CK; EC 2.7.3.2) BB in the sera of 58 cancer patients. A pre-incubation step with an anti-CK-M antibody-coated bead removed M chain components, and CK-BB was quantified with use of an anti-CK-B antibody-coated tube. No cross reactivity was observed with mitochondrial CK or CK-MM; CK-MB cross reacted slightly (1.6%). Macro CK type 1 was measured as CK-BB. Average analytical recovery of purified CK-BB added to serum was 97.7%. Although the enzyme activity of CK-BB is labile, our studies show that this protein is antigenically stable for 12 months when stored frozen. The upper limit of normal for CK-BB concentration was 0.3 micrograms/L (95th percentile, n = 25). Of the 20 cases of breast cancer of various stages, none showed any increases of serum CK-BB. Only two of 18 patients with prostatic carcinoma (stage D), and two of 10 patients with oat-cell carcinoma of the lung had increased concentrations of CK-BB in the serum. Ten patients with squamous cell cancer of the lung had normal concentration of the enzyme. Thus the CK-BB isoenzyme is not frequently increased in cancers of the prostate, lung, and breast, and it has little apparent value as a tumor marker for these diseases.

Diagnosis, Staging, and Surgical Treatment of Prostatic Carcinoma

William J. Catalona, MD, Chief of Urologic Surgery, Washington University School of Medicine, St Louis: A 66-year-old man, during a routine physical examination, was noted to have an area of induration in the right lobe of the prostate. His general health was otherwise good. He had had no symptoms of bladder outlet obstruction and no bone pain. His weight had been stable. He was referred to a urologist for further evaluation. The findings were confirmed on digital rectal examination and he was scheduled for a needle biopsy of the prostate. His medical history and findings from the remainder of the physical examination were normal. Laboratory studies revealed a normal urinalysis, acid phosphatase level, and 12-factor automated analysis (SMA-12), including alkaline phosphatase level. The hemogram was also normal. The needle biopsy revealed a well-differentiated adenocarcinoma of the prostate with tumor being present in cores obtained from both lobes of the prostate.

Diagnosis, staging, and surgical treatment of prostatic carcinoma

Diagnosis, staging, and surgical treatment of prostatic carcinoma

Staging of prostatic carcinoma with radionuclide bone scintigraphy and lymphography.

One hundred patients with histologically proven carcinoma of the prostate were examined by radionuclide bone scintigraphy and bipedal lymphography. In 27 cases the bone scintigram and lymphogram were positive, in 16 the bone scintigram only was positive and in 10 the lymphogram only was positive. Although radionuclide bone scintigraphy is the most useful single investigation for detecting metastatic spread from prostatic carcinoma, lymphography should be performed if the bone scintigram is negative, as it is likely to demonstrate nodal metastases in 18% of patients.

The Value of Computerized Tomography Scan and Magnetic Resonance Imaging in Staging Prostatic Carcinoma: Comparison with the Clinical and Histological Staging

In 21 patients adenocarcinoma of the prostate was staged preoperatively by digital rectal examination, computerized tomography and magnetic resonance imaging. Clinical staging was compared to the postoperative pathological staging. In 11 patients computerized tomography, magnetic resonance imaging and digital rectal examination findings were concordant with the histological examination showing tumors confined to the prostate. In 10 patients no correlation between preoperative staging and histology was noted. Of these cases 8 were understaged by computerized tomography, magnetic resonance imaging and digital rectal examination. In 1 patient magnetic resonance imaging showed false positive findings and in another staging with computerized tomography and magnetic resonance imaging was more accurate than digital rectal examination. Our experience indicates that computerized tomography and magnetic resonance imaging have limited value in the preoperative staging of prostatic carcinoma. Moreover, staging with computerized tomography and magnetic resonance imaging does not significantly improve the information gained by digital rectal examination.

Current problems in staging and grading prostatic carcinoma with special reference to T3 carcinoma of the prostate

The staging and grading results of 107 patients considered to be potential candidates for radical prostatectomy are described. In all patients lymph node status was proven histologically. Understaging of the local tumor was found in 51.4% of the patients. Local overstaging in clinical T3 patients was noted in 23%. Undergrading of the pre-operative biopsy specimen was noted in 42% of the patients, while overgrading occurred in 6% of the patients. False negative frozen sections of pelvic lymph nodes occurred in 7%. The percentage of false negative frozen sections was higher in higher T-categories and higher tumor grades. The presence of lymph node metastases is a function of T-category and tumor grade. In T3G3 patients positive nodes were found in 90% of the cases. Bipedal lymphangiography and CT-scanning were of no value in detecting lymph node metastases in patients not being T3 or G3. In clinical T3 patients total tumor removal, as defined by negative pelvic lymph nodes and negative margins of resection, could be achieved in 30% of the cases.

Lymphocele Formation after Extraperitoneal Pelvic Lymphadenectomy: Possible Predisposing Factors

A retrospective review of 61 patients undergoing pelvic lymphadenectomy was performed to assess possible predisposing factors for lymphocele development. The procedure was done to facilitate staging of prostatic carcinoma in all of the patients. The complication occurred in 9 patients (14.8 per cent). Analysis revealed a statistically significantly higher incidence of lymphoceles in patients without drainage (p less than 0.05) and in patients whose lymph nodes had no metastatic disease (p less than 0.025). Furthermore, 9 patients (without drainage and with nodes that were free of tumor but who received mini-dose heparin therapy) as a subgroup had the highest incidence of lymphocele formation. Although these individual factors have been attributed to this complication after lymphadenectomy they may act synergistically.

Nuclear magnetic resonance in advanced prostate cancer (stage D).

Nuclear Magnetic Resonance (NMR), a recently developed diagnostic method, has proved to be useful in the study of patients with prostatic disease. The authors report their experience with this technique in 10 cases of advanced prostate cancer (stage D) treated with LH-RH agonists (HOE 766-Buserelin). NMR provided information on the size of the prostate, the invasion of the vesical floor and seminal vesicles and the involvement of the pelvic and retroperitoneal nodes. It was also useful for ruling out metastases in the pelvis and spinal column, and showed an excellent correlation with the bone scan. In 2 untreated cases, NMR was sufficient by itself to diagnose metastatic prostate cancer. However, given the current lack of experience, it is not yet possible to draw conclusions concerning the superiority of this technique over other methods in the diagnosis and staging of prostatic carcinoma.

Lymphographic findings in prostatic carcinoma with distant metastases

From January 1976 to December 1981, 25 patients with prostatic carcinoma and distant metastases had lymphangiography (LAG) in their initial workup either to obtain a more precise definition of tumor extension or because at the time of LAG asymptomatic metastases had not yet been detected. In 18 patients extensive bone metastases were present while in seven the only indicator of bone metastases was bone scan (limited bone disease). Positivity rate was 48% (20% in T2 cases, 53% in T3-T4; 29% in limited bone disease, 53% in extensive bone metastases). No correlation was found between LAG positivity and degree of differentiation. Patients with N0 survived longer than patients with N2-N4; however, the difference in survival is not significant and seems to be linked to the extent of bone metastases. Our data substantiate that LAG is of no value in the staging of metastatic prostatic carcinoma.

Percutaneous Lymph Node Aspiration Biopsy and Tumor Grade in Staging of Prostatic Carcinoma

Percutaneous fluoroscopy-guided fine-needle aspiration biopsy was performed for staging procedures in 31 patients with clinically localized carcinoma of the prostate and showed overall accuracy of 93.54%, with a false-negative rate of 6.46%. The Gleason grading system was found to be highly accurate in predicting the absence or presence of nodal metastases in low- and high-grade tumors (Gleason's sums 2, 3, or 4, and 8, 9, or 10). The combination of pelvic node biopsy aspiration and tumor grade can result in a very accurate prediction of nodal involvement, and may spare patients a staging lymphadenectomy or even an unnecessary radical operation.

Magnetic Resonance: Principles and Applications

Magnetic resonance is a unique, noninvasive imaging modality which allows direct, multiplanar imaging and the possibility of obtaining biochemical information in vivo. Presently, MR appears most applicable to the evaluation of central nervous system abnormalities. The high sensitivity of MR in the evaluation of intracranial pathology suggests that it may eventually replace CT for many suspected diseases, if future investigations are able to improve its specificity. As previously noted, MR may be more diagnostic than other radiologic studies in the evaluation of suspected Chiari malformation, syringomyelia, congenital abnormalities, tumors of the spinal axis, and disc space infection. In the chest, MR appears to be more accurate than CT in the determination of the extent of mediastinal tumor, but at present cannot replace CT because of the lack of experience in imaging parenchymal nodules and benign diseases. MR of the breast is promising, but the size of the lesion may prove to be a limiting factor with magnetic field strengths commonly being utilized. There are inherent difficulties in the evaluation of cardiac disease with MR, but it offers a noninvasive method of investigating congenital heart disease and may provide valuable information in suspected myocardial ischemia and altered cardiac function. MR provides a new method of evaluating the vascular system, both in terms of providing anatomic information on large and medium-sized vessels and flow analysis. In the abdomen, MR appears to be most sensitive in the evaluation of suspected hepatic masses, but as with the brain, greater specificity will be needed to replace CT. At the present time, MR offers no distinct advantage over conventional imaging modalities in the evaluation of pancreatic disease, it maybe more accurate than CT in the staging of renal cell carcinoma. Larger studies are needed to determine the role of MR in the investigation of retroperitoneal adenopathy and adrenal abnormalities. In the pelvis, MR offers the hope of earlier diagnosis of prostatic carcinoma and may replace CT for staging of prostatic carcinoma and transitional cell carcinoma of the bladder. Limited MR experience with benign disease of the female pelvis suggests that it is currently more accurately evaluated with ultrasound. MR appears to be highly sensitive and specific for the diagnosis of avascular necrosis and may provide an early clue in suspected osteomyelitis. Finally, in vivo MR spectroscopy may provide unique metabolic information that was unobtainable prior to the advent of magnetic resonance, if this proves to be technically feasible.

Estramustine phosphate as primary therapy for metastatic prostate cancer: Preliminary results of the University of Wisconsin Trial

[onsson and Hogberg were the first to use estramustine phosphate as primary therapy for patients with metastatic prostatic carcinoma;' Their early Iavorable experience prompted them subsequently to initiate a larger phase II trial of 63 patients with resultant objective remissions occurring in 46 (73.0 %) patients. Such encouraging response rates naturally resulted in the establishment of phase III trials comparing estramustine phosphate (Emcyt) to standard estrogen therapy. In one such study, patients with well or moderately well differentiated carcinoma Stages B, C, and D were randomized to receive estramustine phosphate 420 mg p.o. b.i .d, or polyestradiol phosphate one 80-mg IM injection a month plus oral 17-a-ethinylestradiol 2 mg/day for two weeks and thereafter 150 rug/day, There was no significant difference between the two treatment groups except for a somewhat lower frequency of cardiovascular side effects in those patients given estramustine phosphate. In a separate European Organization for Research on Treatment of Cancer (EORTC) trial patients with previously untreated prostatic carcinoma Stages C and D were randomized to diethylstilbestrol 3 mg q. day or estramustine phosphate 560 mg q. day for eight weeks and 280 mg daily thereafter. Although several progress reports of this study have been published which indicate that there is as yet no demonstrable difference between estramustine phosphate and standard estrogen therapy, an indepth analysis of the 278. entered patients is not yet available.P Our experience at the University of \Visconsin with estramustine phosphate for patients with hormone refractory Stage D carcinoma of the prostate prompted us to begin a phase III trial in 1977 comparing estramustine phosphate to diethylstilbestrol (DES) in previously untreated patients with Stage D

Percutaneous lymph node aspiration biopsy and tumor grade in staging of prostatic carcinoma

Percutaneous fluoroscopy-guided fine-needle aspiration biopsy was performed for staging procedures in 31 patients with clinically localized carcinoma of the prostate and showed overall accuracy of 93.54%, with a false-negative rate of 6.46%. The Gleason grading system was found to be highly accurate in predicting the absence or presence of nodal metastases in low- and high-grade tumors (Gleason's sums 2, 3, or 4, and 8, 9, or 10). The combination of pelvic node biopsy aspiration and tumor grade can result in a very accurate prediction of nodal involvement, and may spare patients a staging lymphadenectomy or even an unnecessary radical operation.

Evaluation of a Monoclonal Antibody-Based Immunoradiometric Assay for Prostatic Acid Phosphatase

This report evaluates a new immunoradiometric assay for prostatic acid phosphatase in serum, based on a dual monoclonal antibody reaction system (Hybritech-TANDEM). A solidphase antibody binds the acid phosphatase molecule and a second monoclonal antibody to a different antigenic site serves as the /sup 125/I-radiolabel. The method was tested on 67 patients with various stages of prostatic carcinoma and 134 patients without the disease. It also was compared with a conventional polyclonal radioimmunoassay (NEN) and an enzymatic activity method (duPont aca). The upper limit for the TANDEM assay on nondiseased male patients was found to be 2.0 microgram/L. Based on this upper limit of normal, the diagnostic sensitivity of the method for all cases of prostatic carcinoma was 60%. Researchs could not distinguish the enzyme released in abnormal amounts due to benign prostatic hypertrophy and certain nonprostatic malignant diseases from that of prostatic carcinoma. The diagnostic specificity was calculated at 95%. For the clinically undetectable Stage 1 disease, sensitivity was 44% (four abnormal values out of nine cases). The TANDEM procedure is simple to use and reproducible.

Transurethral resection in prostatic carcinoma

Transurethral resection in prostatic carcinoma as a possible cause of dissemination of tumor cells and consequently of accelerated metastatic growth has been a matter of discussion for years. In order to determine whether transurethral resection plays a role in the dissemination of prostatic cancer the following retrospective study was performed. Forty patients with prostatic carcinoma stage C who underwent palliative transurethral resection were compared with 12 patients without transurethral resection. Both groups of patients were compared in regard to survival rate, formation of bone and soft tissue metastases as well as to the increase in acid phosphatase and the development of supravesical urinary tract obstruction. As regards the frequency distribution for age at the time of diagnosis there was no difference between the two groups of patients. Regarding the survival rate there is no statistically significant difference between patients who undervent transurethral resection and those who did not. Data on the progression to stage D disease show no statistically significant difference between two groups of patients; therefore transurethral resection in prostatic carcinoma is not the cause of accelerated metastatic growth.