Two different lymph node metastatic patterns of a prostatic cancer

Metastatic Prostatic Adenocarcinoma Masquerading as Pulmonary Tuberculosis: A Case Report

Prostate carcinoma is one of the most common malignancies in the elderly male population in India as well as worldwide, and its incidence has been on the rise in the younger age groups as well. The annual incidence rate of prostate cancer in India ranges from 5.0 to 9.1 per 100,000 people. It commonly metastasizes to the bone, regional lymph nodes, and in rare cases, to the lung, liver, and brain. Pulmonary manifestations of metastatic prostate carcinoma are rare with pulmonary lesions being part of the initial pattern of metastasis in only 2% of prostate malignancies. We report the case of a 53-year-old male who presented with breathlessness and hemoptysis, which was initially diagnosed as pulmonary tuberculosis and later found to be a case of metastatic prostatic adenocarcinoma.

Validating Modern NRG Oncology Pelvic Nodal and Groupe Francophone de Radiothérapie Urologique Prostate Bed Contouring Guidelines for Post-Prostatectomy Salvage Radiation: A Secondary Analysis of the LOCATE Trial

PURPOSE

We used the patterns of recurrence on ¹⁸F-fluciclovine positron emission tomography (PET)-computed tomography (CT) in patients enrolled in the LOCATE trial after prostatectomy to evaluate how well the most recent NRG Oncology and Groupe Francophone de Radiothérapie Urologique (GFRU) contouring recommendations encompassed all sites of recurrence in the prostate fossa and pelvic nodes in comparison to former Radiation Therapy Oncology Group (RTOG) recommendations.

METHODS AND MATERIALS

Patients with biochemically recurrent prostate cancer after radical prostatectomy with a positive finding within the prostate fossa or pelvic nodes on ¹⁸F-fluciclovine PET/CTs were identified from the LOCATE patient population. Areas of gross disease were delineated. Prostate fossa contours were delineated using both the 2010 RTOG consensus guidelines and the recently published 2020 GFRU consensus guidelines. Pelvic nodes were contoured with both the 2009 RTOG consensus guidelines and the 2020 NRG consensus guidelines. The performance of the contouring guidelines was assessed by determining what proportion of gross recurrent lesions were encompassed completely or marginally.

RESULTS

Of the 213 patients within the LOCATE trial, 45 patients were eligible for analysis with positive ¹⁸F-fluciclovine PET findings. Of the 30 total prostate fossa recurrences, the 2010 RTOG contour covered 20 (67%) and missed or marginally covered 10 (33%). The 2020 GFRU contour covered 27 recurrences (90%), and missed or marginally covered 3 (10%). Of the 43 total nodal recurrences, the 2009 RTOG pelvic nodal contour covered 29 nodes (67%), and missed or marginally covered 14 (32%). The 2020 NRG pelvic nodal contour covered 43 nodes (100%), with no misses or marginal coverage.

CONCLUSIONS

This secondary analysis of the LOCATE trial exemplifies the improved coverage of the latest prostate fossa contouring recommendations from the GFRU. Similarly, it also validates the updated 2020 NRG pelvic nodal contouring guidelines by demonstrating improved coverage of recurrent disease in this patient population.

Advanced synchronous rectal and prostate cancers diagnosed by lateral lymph node dissection: A case report

Introduction

Rectal and prostate cancers are common cancers occurring globally, and both can metastasize to the pelvic lateral lymph nodes (LLNs).

Presentation of case

A 69-year-old man, presenting with blood in stool, was diagnosed with rectal cancer. Computed tomography revealed a 7-mm LLN in the right internal iliac artery region, leading to the suspicion of metastasis. The patient underwent laparoscopic low anterior resection and LLN dissection. Histopathological findings of the metastatic tissue in the LLN were different than that of rectal cancer, and endocrine tumor was suspected. Immunostaining performed based on high serum prostate-specific antigen (PSA) level revealed positivity for PSA and α-methylacyl-CoA racemase in the dissected LLN. Thus, he was diagnosed with synchronous rectal and prostate cancers and received hormonal therapy for stage IV prostate cancer, which led to a dramatic reduction in PSA level after three months. He was followed regularly and did not relapse or experienced disease progression for either cancer for approximately four years after the initial diagnosis.

Discussion

Few studies reported synchronous rectal and prostate cancers, both of which can metastasize to pelvic LLNs. However, preoperative diagnosis of the primary cancer metastasizing to the LLNs is challenging. Treatment of synchronous rectal and prostate cancers requires a strategy to diagnose each tumor stage and corresponding degree of progression because lymph node metastases affect staging in both cancers.

Conclusion

Lymph node dissection may be useful in determining progression and treatment plan in cases of concurrent rectal and prostate cancers with suspected LLN metastasis.

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Lateral lymph node (LLN) metastasis is rarely reported in synchronous rectal and prostate cancer.

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LLN metastasis impacts staging in synchronous rectal and prostate cancer.

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Preoperative identification of the origin of LLN metastasis is difficult in such cases.

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LLN dissection may be useful to assess progression and treatment of synchronous cancers.

Metastatic prostate adenocarcinoma to cervical lymph nodes: an unusual diagnosis on fine-needle aspiration biopsy

INTRODUCTION

Metastatic prostatic adenocarcinoma (PAC) has mostly involved the pelvic lymph nodes; metastases to the cervical lymph nodes are exceedingly rare.

MATERIALS AND METHODS

A retrospective review of cytopathology files (January 1990 to March 2019) identified 13 cases of metastatic PAC to cervical lymph nodes diagnosed using fine-needle aspiration biopsy (FNAB). The clinical and demographic information were collected from the electronic medical records, and the slides were reviewed.

RESULTS

A total of 13 male patients with a mean age at FNAB 69 years (range, 61-86 years); 12 patients had a known history of PAC. In the patient without a history of PAC, the FNAB finding had been misinterpreted as papillary thyroid carcinoma. The interval between the original diagnosis and cervical lymph node metastasis was 98.5 months (range, 1-288 months). Most involved the left side (85%). Most smears had a clean background with few lymphocytes (46%) and numerous cellular clusters in flat sheets and acini (62%) and were composed of polygonal cells (46%) with round-oval shaped nuclei and indistinct cell borders (92%). The cytoplasm was granular (61%) or scanty (46%). The nuclei were uniform, size ≥2 times that of a neutrophil (69%). Prominent nucleoli and anisonucleosis were seen in 54% of cases; cellular pleomorphism was infrequent (30%). Immunostains confirmed the prostate origin in 7 tissue cores.

CONCLUSIONS

Metastatic PAC to the cervical lymph nodes occurs infrequently. If the history is unknown, cases can be misdiagnosed as metastases from cervical neoplasms. The findings indicating metastatic PAC to the cervical lymph nodes on FNAB include involvement of left-sided cervical lymph nodes in elderly male patients and cellular smears composed of uniform polygonal cells, arranged in flat sheets and acini, with granular cytoplasm, indistinct cell borders, and round-oval nuclei with prominent nucleoli.

Role of Para-aortic Radiotherapy in the Management of Prostate Cancer

Recent studies assessing the patterns of failure following locoregional definitive therapy suggest that recurrences do happen in the adjacent most proximal drainage sites, not infrequently occurring within the common iliac and para-aortic regions. This pattern of recurrence and identification at initial presentation is being increasingly recognised using novel imaging techniques and there is limited evidence on how to manage these patients. We are awaiting definitive evidence regarding the clinical benefit of whole pelvic radiotherapy, and currently there is no consensus as to the optimal superior border. There is some acknowledgement that the superior border should encompass the common iliac nodal region. However, whether it should be extended even more proximally is currently unknown. Prospective randomised trials are required to determine if there is a role for extending the radiotherapy field in patients with or at high risk of para-aortic metastases.

Approaching spinal metastases spread profile

BACKGROUND

Spinal metastases cause significant morbidity. The vertebral column is the most common site of cancer metastasis, however predilection of metastases for the spine is not fully understood.

OBJECTIVE

The aim of the present investigation was to obtain a better description of the distribution of spinal metastases. The main objective of our study was to figure out how malignant cells disseminate within the spine and determine a potent mapping or profile of the metastatic spread routes.

STUDY DESIGN

A prospective French national multicenter database.

METHODS

740 consecutive patients were treated for spine metastasis (SpM) between January 2014 and 2017. A categorisation of the anatomical distribution of spine lesions was conducted.

RESULTS

One hundred and seventy patients (22.9% of series) presented cervical SpM, 440 (60%) lumbar SpM, and a majority 530 (71.6%) at the thoracic vertebral level. Metastases were more often present in the vertebral body (645 patients, 87.2%) than in a posterior location (278 patients, 37.6%, p < 0.0001). 212/740 patients (28.6%) presented circumferential spine involvement (body and posterior elements). An associated epiduritis was presented in 404 patients (54.6%). Primitive neck tumors spread towards the cervical spine: ENT (34.8%, p = 0.049), thyroid (33.3%, p = 0.043) whereas pelvic tumors targeted the lumbar spine: prostate (72%, p = 0.011), bladder (75%, p = 0.047). All tumors presented a tropism for thoracic vertebrae. Significant tumor/vertebrae associations were identified: lung (p = 0.004) and thyroid (p = 0.028) for L₁, bladder for L₅ (p = 0.0025), breast for C₆ (p = 0.006), Prostate for L₁-L₄ (p = 0.002-0.04), multiple myelomas for C₇, p = 0.03, T₃-T₇ (p < 0.0001-0.025) and L₁-L₄ (p = 0.004-0.027). Spine was the latest organ affected by metastases with a median-free survival of 4.2 months (SD 1.8, p = 0.001).

CONCLUSIONS

Although we determined that some tumors have a significant propensity to localise at certain vertebral level, it remains premature to conclude on a spinal metastases profile. To date, it is too early to provide recommendations in imaging follow-up or in preventive therapeutic based on this mapping of spine metastases.

Thoracic Manifestations of Genitourinary Neoplasms and Treatment-related Complications

Genitourinary (GU) malignancies are a diverse group of common and uncommon neoplasms that may be associated with significant mortality. Metastases from GU neoplasms are frequently encountered in the chest, and virtually all thoracic structures can be involved. Although the most common imaging manifestations include hematogenous dissemination manifesting with peripheral predominant bilateral pulmonary nodules and lymphatic metastases manifesting with mediastinal and hilar lymphadenopathy, some GU malignancies exhibit unique features. We review the general patterns, pathways, and thoracic imaging features of renal, adrenal, urothelial, prostatic, and testicular metastatic neoplasms, as well as provide a discussion of treatment-related complications that might manifest in the chest. Detailed reporting of these patterns will allow the imager to assist the referring clinicians and surgeons in accurate determination of the stage, prognosis, and treatment options available for the patient. Awareness of specific treatment-related complications further allows the imager to enhance patient safety through accurate and timely reporting of potentially life-threatening consequences of therapies.

Oligometastases in prostate cancer: restaging stage IV cancers and new radiotherapy options

There are various subgroups of patients with metastatic prostate cancer: polymetastatic, oligometastatic, or oligo-recurrent cancers whose progression follows different courses and for whom there are different treatment options. Knowledge of tumor dissemination pathways and different genetic and epigenetic tumor profiles, as well as their evolution during disease progression, along with new diagnostic and therapeutic advances has allowed us to address these situations with local ablative treatments such as stereotactic body radiation therapy or stereotactic radiosurgery. These treatments provide high rates of local control with low toxicity in metastatic spread for primary cancers including those of pulmonary, digestive, and renal origin, while these types of treatments are still emerging for cancers of prostatic origin. There are several retrospective studies showing the effectiveness of such treatments in prostate cancer metastases, which has led to the emergence of prospective studies on the issue and even some phase II studies intended to prevent or delay systemic treatments such as chemotherapy. Here we collect together and review these past experiences and the studies currently underway. These types of radiotherapy treatments redefine how we approach extracranial metastatic disease and open up new possibilities for combination therapy with new systemic treatment agents.

Circulating tumor cells in prostate cancer

Circulating tumor cells (CTCs) can provide a non-invasive, repeatable snapshot of an individual patient's tumor. In prostate cancer, CTC enumeration has been extensively studied and validated as a prognostic tool and has received FDA clearance for use in monitoring advanced disease. More recently, CTC analysis has been shifting from enumeration to more sophisticated molecular characterization of captured cells, which serve as a "liquid biopsy" of the tumor, reflecting molecular changes in an individual's malignancy over time. Here we will review the main CTC studies in advanced and localized prostate cancer, highlighting the important gains as well as the challenges posed by various approaches, and their implications for advancing prostate cancer management.

Pneumothorax as a Presenting Clinical Manifestation of Metastatic Prostate Cancer

Pulmonary metastases are not encountered commonly in patients with prostate cancer. Pulmonary metastases with pneumothorax as a presenting clinical manifestation in newly diagnosed prostate cancer are very rare. Here, we present the case of an 82-year-old patient who was admitted to our center with a chief complaint of worsening dyspnea over the past few days. The chest X-ray and computed tomography (CT) showed left pneumothorax and bilateral lung opacities as well as generalized lymphadenopathy and diffuse bony metastases. After a series of workup including cervical lymph node biopsy with immunohistochemical staining, abdomen CT, serum prostate-specific antigen (PSA), and transrectal ultrasonography (TRUS), he was proved to have prostate cancer with multiple lung, bone and lymph node metastases. This case is reported because of the rarity for a prostate carcinoma presented clinically with an unusual pulmonary manifestation.

Unusual presentations of prostate cancer: A review and case reports

Objective

To report our institutional experience with some rare presentations of prostate cancer, as prostate cancer is a common problem and affects a large group of men during their lifetime, but a few studies report unusual presentations of metastatic prostate cancer.

Methods

All possible clinical and pathological data were collected for six relevant patients with prostate cancer and unusual metastases who were identified at our institution. PubMed was searched for unusual presentations of prostate cancer in the last 20 years (1982–2012) and all relevant publications were assessed. The authors discussed the reports and selected those articles of major clinical significance to include in a review.

Results

We identified 19 reports of major clinical significance and reviewed them. As in the cases from our institution, supraclavicular lymphadenopathy, isolated upper ureteric obstruction and severe obstructing constipation were some of the rare presentations encountered at other institutions, and reported mostly as sporadic case-reports.

Conclusion

Prostate cancer should be always considered in the differential diagnosis of elderly men presenting with supraclavicular lymphadenopathy, hydroureteronephrosis or constipation, even in the presence of a normal digital rectal examination and low serum total prostate-specific antigen (PSA) levels. PSA immunohistochemical staining should be used in doubtful cases.

Common primary tumours of the abdomen and pelvis and their patterns of tumour spread as seen on multi-detector computed tomography

BACKGROUND: Multidetector computed tomography (MDCT) has become the main investigation of choice for staging of many cancers. AIM: The purpose of this pictorial review is to discuss the imaging appearances on CT of some of the more common cancers arising within the abdomen and pelvis and to describe their typical sites of local, nodal and haematogenous tumour spread. METHODS: Cancers arising from the stomach, pancreas, colon, kidney, ovary and prostate will be reviewed. RESULTS: Awareness of the characteristic sites of tumour spread is important to allow accurate identification of all sites of disease. CONCLUSION: This will clearly have an impact on both patient management and prognosis.

Metastatic prostate adenocarcinoma presenting with pulmonary symptoms: a case report and review of the literature

Introduction

Prostate cancer has a high tendency to spread to bone. Pulmonary metastasis and generalized lymphadenopathy commonly develop after pelvic and bone involvement have already occurred. Few patients with prostate cancer present initially with symptomatic metastatic lung lesions and lymphadenopathy without any other concomitant distant dissemination.

Case presentation

We report a case of a 73-year-old white male who sought medical help for symptoms of cough, hemoptysis, and dyspnea. A chest X-ray was done revealing multiple "cannon ball" infiltrates involving all segments of the lung parenchyma. Fine-needle aspiration cytology under computed tomography guidance of a subpleural lesion revealed adenocarcinomatous cells. Despite the absence of any detectable osseous lesions and with the presence of multiple hilar, mediastinal, para-aortic, and pelvic lymphadenopathy, the patient had a complete work-up in search for the primary adenocarcinoma. His prostate specific antigen was 146 ng/ml and a prostatic biopsy done, revealing an acinar prostatic adenocarcinoma. A tru-cut biopsy of a lung lesion under computed tomography guidance showed a metastatic prostatic adenocarcinoma positive for prostate specific antigen stain.

Conclusion

This case sheds light on an unusual metastatic pattern of prostatic adenocarcinoma. It also emphasizes the importance of including prostate cancer in the differential diagnosis of men with adenocarcinoma of unknown origin.

[Treatment of specific complications of locally advanced prostate cancer]

Despite improved screening methods and earlier detection of prostate carcinoma, the complications of locally advanced disease remain a challenge for urologists. The spectrum of possible complications includes subvesical obstruction, hydronephrosis, hematuria, pain, and local invasion of adjacent organs. Urinary diversion, palliative transurethral resection of the prostate, and endoscopic diathermy are classic procedures. Urethral stenting, laser evaporation, and selective arterial embolization are alternate approaches for treating these complex cases. Cystoprostatectomy and pelvic exenteration are ultimate options for patients with chronic pain and debilitating local symptoms.

Imaging in Oncology from The University of Texas M. D. Anderson Cancer Center: Diagnosis, Staging, and Surveillance of Prostate Cancer

OBJECTIVE

The purpose of this article is to discuss the epidemiology, risk factors, and presentation of prostate cancer. After reviewing the prostate anatomy, the article will show how imaging plays an important role in establishing the diagnosis, staging, and monitoring the therapeutic response in prostate cancer, with a focus on adenocarcinomas.

CONCLUSION

Imaging studies, in the appropriate laboratory and clinical context, contribute essential information that enhances the capacity to provide individualized risk stratification, a suitable treatment strategy, and monitoring for the patient with prostate cancer.

Technology Insight: monoclonal antibody imaging of prostate cancer

Imaging is a critical component of diagnosis, staging and monitoring, all of which factor heavily in treatment decision-making for cancer patients. Agents, such as antibodies, can target molecules that are relatively unique to cancer cells. Prostate-specific membrane antigen (PSMA) is the most well-established, highly restricted prostate-cancer-related cell membrane antigen known. Ten years ago, the FDA approved (111)In-capromab pendetide for use in imaging soft-tissue, but not bone, sites of metastatic prostate cancer for presurgical staging or the evaluation of PSA relapse after local therapy. For presurgical patients with high-risk disease but negative bone, CT and MRI scans, capromab demonstrated the ability to identify some patients with positive nodes, thereby sparing them an unnecessary surgical procedure. But there have been no follow-up studies to indicate that high-risk patients with a negative capromab scan have a lower failure rate after surgery. In the setting of PSA relapse, capromab is compromised by its inability to sensitively image bone metastases; bone is the first site of metastatic prostate cancer in 72% of patients. The problem with imaging bone metastases is that capromab detects an antigenic site on the intracellular portion of PSMA-a site not accessible to circulating antibodies. Early results indicate that second-generation antibodies that target the extracellular domain of PSMA might provide significant benefits in the imaging of prostate cancer.

Metastatic prostate cancer presenting as an asymptomatic neck mass

Prostate cancer often metastasizes to the regional lymph nodes, but metastases to distant supradiaphragmatic lymph nodes are uncommon. Rare case reports describe cervical lymph node metastases as the first clinical manifestation of prostate cancer, but only in the setting of widely disseminated disease. We present the unusual case of an 84-y-old male with a known history of prostate cancer and recurrent disease limited to the left supraclavicular lymph nodes.

MEDICAL AND SURGICAL PALLIATIVE CARE OF PATIENTS WITH UROLOGICAL MALIGNANCIES

PURPOSE

Urological malignancies are relatively common and patients often live many years with disease. There are many effective medical and surgical palliative treatments, although few comprehensive guidelines have been published. We reviewed the various palliative treatments available for the 3 most common urological malignancies, namely prostate cancer, bladder cancer and renal cancer.

MATERIALS AND METHODS

A literature search of the last 15 years was performed using MEDLINE/PubMed. In addition, relevant journals were targeted for specific information related to this review. Our clinical experience was combined with the current literature to create guidelines for palliative care.

RESULTS

Several effective treatments are available for the palliative care of patients with prostate, bladder or renal cancer. Options in palliative care are varied with regard to invasiveness, morbidity, risks and benefits. The algorithms described provide a framework to a sequential approach to achieving palliation. Urologists are central to initiating care and referrals to improve outcomes in these patients.

CONCLUSIONS

Palliative care includes disease directed treatment as well as functional, psychosocial and spiritual support. Disease directed therapy and palliative care should be provided simultaneously throughout illness. Improved quality of care and quality of life as well as physician satisfaction are frequent outcomes of this approach. Supportive care begins at initial diagnosis and it should be flexible to meet the changing needs of patients with cancer and their families.

Clinical significance of pulmonary metastases in stage D2 prostate cancer patients

Several prognostic factors such as the extent of bone metastases (EOD) in advanced prostate cancer (PCa) have been reported. Metastasis of the lung is rarely a significant clinical factor in the management of prostate cancer. The present study evaluates the clinical significance of lung metastases. We retrospectively reviewed the PCa database to identify patients with pulmonary metastases at initial diagnosis. The medical records of the patients were examined with respect to age, histologic grade, EOD score, marker response to endocrine therapy and clinical outcome. We then compared several potential clinical factors between patients with and without pulmonary metastases. Next, we retrospectively reviewed autopsy records of 60 Japanese patients who died of hormone-refractory metastatic PCa with particular focus upon metastatic profiles. A comparative study of stage D(2) patients with (n=20) and without (n=77) pulmonary metastases found no significant differences in EOD score, performance status, marker response and survival. Only tumor grade was better in the group with, than without pulmonary metastases (P=0.0120, chi-square analysis). In the series of autopsies, we found pulmonary metastases in 38 cases (63%), following metastases of the bone (57 cases, 95%) and lymph nodes (52 cases, 87%). A retrospective analysis of survival showed that patients with bone or lymph node metastases had a positive relative risk. In contrast, lung metastasis could be a positive prognostic indicator, although the findings were not statistically significant. These data suggest that the presence of pulmonary metastasis has no ominous impact on clinical course and disease outcome even in patients with disseminated prostate cancer.

Treatment of advanced prostate cancer

OBJECTIVES

To review the management of advanced prostate cancer, including symptom management, hormonal therapy, and the use of chemotherapy.

DATA SOURCES

Published articles and book chapters on advanced prostate cancer.

CONCLUSIONS

Advanced prostate cancer is a common problem that has a significant impact on the patient's quality of life. Multiple complications may develop during the course of the disease. Treatment may include local and systemic approaches. Advances in disease treatment include hormonal therapies and chemotherapy. Additional research is needed to determine the optimal treatment for these men.

IMPLICATIONS FOR NURSING PRACTICE

Patient education is crucial to the management of advanced prostate cancer in all practice settings. Early and prompt recognition of disease complications will enhance the patient's quality of life.

Multicenter ProstaScint imaging findings in 2154 patients with prostate cancer. The ProstaScint Imaging Centers

OBJECTIVES

To report the results of a retrospective study of 2290 ProstaScint scans of 2154 patients with prostate carcinoma done at 15 institutions.

METHODS

The results were analyzed by logistic regression after stratification of the patients into four groups: group 1, newly diagnosed; group 2, after radical prostatectomy with a rising prostate-specific antigen (PSA) level; group 3, after radiation therapy with a rising PSA level; and group 4, after hormonal therapy.

RESULTS

The PSA level and ProstaScint scans positive in the prostate bed (P <0.001) and for pelvic metastases (P <0.001), but not for extrapelvic metastases, correlated significantly in group 1 patients. In group 2, the association for detecting fossa recurrence was weaker (P = 0.033) and was insignificant for pelvic and extrapelvic metastases. Patients in group 3 also exhibited a weak PSA-ProstaScint association for detecting fossa recurrence (P = 0.038), and was insignificant for pelvic and extrapelvic metastases. No significant PSA-ProstaScint correlation was found in patients in group 4 for fossa recurrence, pelvic or extrapelvic metastases. The distribution of positive ProstaScint results among the prostate/prostate bed, pelvic nodes, and extrapelvic nodes was nearly equal for all groups, except that a significantly greater percentage of extrapelvic metastases was found in the hormonal group (group 4). The ProstaScint results were independent of the Gleason score for 260 patients before and 285 patients after therapy.

CONCLUSIONS

The results of this study underscore the complementary diagnostic value of ProstaScint to PSA level and Gleason score as an independent indicator of prostate cancer recurrence and metastases and in identifying extrapelvic metastases in both newly diagnosed and recurrent prostate cancer.

Radioimmunoguided surgery using indium-111 capromab pendetide (PROSTASCINT) to diagnose supraclavicular metastasis from prostate cancer

A 59-year-old man presented with a Gleason score of 4 + 4 = 8 prostate cancer and with multiple bilateral pelvic nodes involved at open pelvic lymph node dissection. On indium-111 capromab pendetide (ProstaScint) scan, there was increased tracer deposition in the prostate, the mesenteric nodes, the right pulmonary hilum, and the left supraclavicular fossa. The ProstaScint injection was repeated, and the gamma probe was used to localize tissue that accumulated radiotracer. Two nodes were excised, one that exhibited increased uptake and one that did not. The radioactive lymph node contained metastatic prostate cancer. No malignancy was found in the second node.

Follow-up ProstaScint scans verify detection of occult soft-tissue recurrence after failure of primary prostate cancer therapy

BACKGROUND

A reliable imaging modality is required to uncover occult soft- tissue recurrence after failure of primary prostate cancer therapy. This retrospective study was done to evaluate the ability of the (111)Indium-labeled monoclonal antibody (ProstaScint(R)) scan in detection of prostatic bed recurrence and/or metastases to regional and/or distant lymph nodes.

METHODS

One hundred sequential patients were evaluated with repeated ProstaScint(R) scans because of evidence of recurrence during the course of their disease. These 100 patients were followed closely from November 1994 and April 1999, and had concurrent bone scans and serum prostate-specific antigen (PSA) evaluations. They have had hormone therapy (n = 53) and/or experienced a rising PSA after radical prostatectomy (n = 38) or after radiation therapy (n = 56). Scan images were scored 0-3, where score 0 = negative, score 1= prostate bed uptake, score 2 = regional lymph node uptake, and score 3 = distant lymph node uptake. In each patient, the uptake of the follow-up scan(s) was compared to that of the initial scan.

RESULTS

The median age was 70 years (range, 45-87), and 23 patients had a positive bone scan. The average PSA was 40.5 ng/ml (standard deviation, 223.5). There was 257 scans representing 100 patients. All patients had at least 2 scans, 35 patients had 3 scans, and 11 patients had 4 scans. No individual exhibited detectable adverse clinical reactions during or after the scan. The findings of the initial and consecutive scans were anatomically consistent in 79%, whereas in 21% there were skip metastases. In 24 patients the lesions progressed by scan and PSA, 10 patients showed progression of scan but no PSA progression, 49 patients showed no change, and 17 patients showed a remission related to adjuvant therapy.

CONCLUSIONS

The consistency on repeating the scan (79%) and the high percentage of patients showing persistent uptake at the prostate bed (43%) as well as the percentage of detection of regional nodes (20%) and distant nodes (32%) reflects the importance of using the ProstaScint(R) scan in finding occult recurrences after primary treatment failure of prostate cancer. These results are similar to those reported earlier in autopsy series studies in similar populations.

The dual-isotope ProstaScint imaging procedure: clinical experience and staging results in 145 patients

PURPOSE

Whole-body, regional planar, and SPECT imaging using the In-111-labeled monoclonal antibody capromab pendetide (In-111 MAb; ProstaScint) has been shown to increase the detection of early disease spread in patients with prostate cancer. However, recognition of metastatic tumor sites can be difficult, especially if the involved nodes are near blood vessels. We have developed an alternate approach to the identification of metastatic sites that is based on a single simultaneous In-111 MAb and Tc-99m RBC SPECT acquisition of the pelvis and abdomen on day 5 after injection. We have also developed software that dynamically subtracts the Tc-99m RBC data set (vascular component) from the In-111 MAb data set (prostate and lymph node component), which allows for easier identification of metastatic sites.

METHODS

We evaluated the effectiveness of ProstaScint for staging 145 patients with prostate cancer, 19 newly diagnosed and 126 with recurrence, using these two modifications.

RESULTS

With clinical follow-up in 13 of 19 (68%) patients with primary disease, 10 of 13 (78%) had organ-confined disease. With follow-up in 64 of 126 (51%) patients with possible recurrent disease, 49 of 64 (77%) were found to have prostatic fossa activity only. Disease stage was deemed more advanced in 3 of 13 (22%) patients with primary cancer and in 13 of 64 (20%) of those with recurrent disease based on ProstaScint findings when all other imaging tests were inconclusive. Six patients with recurrent disease had negative results of their scans. In the 16 patients with more advanced disease, 3 of 59 lesions (5%) were documented as false positive, and there were no reported cases of false-negative findings.

CONCLUSIONS

Using both the dual-isotope procedure and the subtraction analysis software with the ProstaScint examination provides additional information for staging primary and possibly recurrent prostate cancer compared with standard imaging techniques.

ProstaScint scan may enhance identification of prostate cancer recurrences after prostatectomy, radiation, or hormone therapy: analysis of 136 scans of 100 patients

BACKGROUND

Primary extraprostatic spread or failure after prostate cancer treatment can occur locally in the prostatic fossa and/or metastasize to regional and/or distant lymphatics and/or in bone. We evaluated the ability of the ProstaScint (Cytogen Corp., Princeton, NJ) scan to identify soft tissue recurrence of prostate cancer in patients who failed primary treatment, and we monitored their responses to a secondary treatment.

METHODS

The 111indium-labeled monoclonal antibody (ProstaScint) was evaluated in a series of 136 consecutive scans associated with a complete set of relevant clinical and biochemical data. These scans represented 100 patients, imaged between November 1994-May 1998, who underwent a definitive prostate cancer treatment followed by evidence of recurrence. All patients had serum prostate-specific antigen (PSA), Western-blot serum prostate-specific membrane antigen (PSMA), and bone scans. Prostatic fossa and/or lymph node biopsies were available in 33 patients.

RESULTS

Overall, no adverse reactions were related to any of the radioactive antibody infusions. The average age was 69 years (range, 48-89 years), serum PSA was 55.9 ng/ml (range, 0-2,185 ng/ml), and serum PSMA was 0.32 (relative intensity levels range, 0.04-0.55). The initial therapies given were radical prostatectomy (55 scans), prostate radiation (74 scans), and/or hormonal therapy (77 scans). Twelve patients exhibited a negative scan. Local recurrence alone was identified in 58 scans (42.6%). Lymph node metastases were identified in 66 scans (48.5%). Of these, 21 had regional metastases alone, and 45 had distant lymph node metastases. Ten scans showed skip lymph node metastases without regional failure. PSA significantly correlated with negative, pelvic, and extrapelvic scan findings (P < or = 0.02). PSMA correlated best with pelvic recurrence and extrapelvic metastases in prostatectomized patients. Thirty-four patients had repeated scans for monitoring treatment response. Of these patients, 19 (56%) showed progression on the second scan, consistent with persistent increase in PSA and PSMA levels in all but 2 patients. Another 11 patients showed no change, and 4 patients showed partial remission, suggesting a response to the salvage treatment. All 20 positive prostate biopsies and 4 of the 7 positive lymph node biopsies correlated with ProstaScint findings, whereas 4 of the 6 patients with a negative biopsy had negative scans (i.e., 89% sensitivity and 67% specificity). Bone metastases were identified in 42 bone scans; 45% of these showed no lymph node metastasis on ProstaScint. In another 24 patients (57%), bone metastases were detected on ProstaScint examinations.

The role of monoclonal antibody in the management of prostate adenocarcinoma

PURPOSE

A study using monoclonal antibody ProstaScint was conducted to determine the role of radioscintigraphy for evaluation of patients with adenocarcinoma of the prostate. Previous evaluations determining sensitivity and toxicity for this agent were conducted in a multicenter study.

MATERIALS AND METHODS

ProstaScint scans were used for preoperative staging in patients presumed to be candidates for total prostatectomy and a subsequent study was performed for the detection and localization of recurrent prostate cancer following definitive therapy.

RESULTS

The monoclonal antibody scan detected localized recurrent cancer in 43 patients who were possible candidates for external beam radiation therapy.

CONCLUSIONS

The monoclonal antibody conjugate ProstaScint provides additional information in detection and localization of recurrent prostate cancer and would be helpful in the selection of patients for subsequent external beam radiation therapy.

111Indium-capromab pendetide in the evaluation of patients with residual or recurrent prostate cancer after radical prostatectomy. The ProstaScint Study Group

PURPOSE

Standard diagnostic methods are limited for detecting distant metastases in patients with prostate cancer in whom the only evidence of disease after radical prostatectomy is a detectable prostate specific antigen (PSA) level. We evaluated the role of immunoscintigraphy with the radiolabeled monoclonal antibody, 111indium ((111)In)-capromab pendetide, to differentiate between local and distant recurrence in this patient population.

MATERIALS AND METHODS

We enrolled 183 men who had undergone radical prostatectomy in whom PSA later increased. Gamma camera images were acquired twice after infusion of a single dose of (111)In-capromab pendetide.

RESULTS

Immunoscintigraphy revealed disease in 108 of 181 patients (60%) with interpretable scans. The antibody was localized most frequently to the prostatic fossa (34% of the cases), abdominal lymph nodes (23%) and pelvic lymph nodes (22%). Of the 181 men the scan localized the antibody outside the prostatic fossa in 42%. Half of the positive localizations in the fossa were confirmed by biopsy.

CONCLUSIONS

These findings suggest that immunoscintigraphy with (111)In-capromab pendetide can assist in determining the extent of disease in patients who have increasing PSA after prostatectomy.

Preliminary imaging results using In-111 labeled CYT-356 (Prostascint) in the detection of recurrent prostate cancer

To evaluate whether In-111 capromab pendetide (an antibody conjugate directed to a glycoprotein found primarily on the cell membrane of prostate tissue) radioimmunoscintigraphy can localize residual or metastatic prostatic carcinoma in 15 patients after prostatectomy and lymphadenectomy for prostatic carcinoma with rising serum prostate-specific antigen. One patient with 0.6 ng/ml serum prostate-specific antigen had normal imaging results and 14 patients had scintigraphic evidence of residual prostatic bed or metastatic prostatic carcinoma. Two patients with borderline abnormal bone scans had abnormal activity in the same regions on In-111 capromab pendetide images. All patients had negative radiographic abdominal and pelvic cross-sectional prestudy images, and there were no adverse effects related to In-111 capromab pendetide infusion and little human antimouse antibody response.

Monoclonal antibody imaging of occult prostate cancer in patients with elevated prostate-specific antigen. Positron emission tomography and biopsy correlation

The utility of monoclonal antibody (MAb) imaging for detection of occult recurrent prostate cancer was investigated in 14 patients with elevated serum prostate-specific antigen at least 3 months after therapy. All were imaged with capromab pendetide (CYT-356) and subsequently had biopsies of the prostate bed. Ten also had PET scans with F-18 fluorodeoxyglucose. Ten MAb scans were positive for tumor in the prostate bed and eight showed lymph node metastases. Six of the seven patients with positive biopsies had positive MAb scans, one had a negative scan. Three of the seven patients with negative biopsies had negative MAb scans, four had positive scans. Of the six patients with positive biopsies who had PET scans, one was positive, five were negative. Two of four patients with negative biopsies had negative positron emission tomography scans, two were positive. MAb imaging is superior to PET scan for identifying recurrent disease in the prostate bed. Assuming no false-negative biopsies, the positive predictive values for MAb and PET scan are 60% and 33%, negative predictive values are 75% and 29% and sensitivities are 86% and 17%. Additional investigation is necessary to determine if MAb uptake in lymph nodes is predictive of metastatic disease.

Deoxythymidine kinase in the staging of prostatic adenocarcinoma

The role of prostate-specific antigen in the management of prostatic adenocarcinoma is still not fully ascertained. Its place in the monitoring of patients who have undergone radical treatment is without question but its role in the primary assessment of a lesion is a point of continuous discussion. This study reports the analysis of prostate-specific antigen (PSA) in 92 patients with different stages of prostatic adenocarcinoma prior to treatment; in the case of the localized lesions, this was based to a great extent on the findings at lymphadenectomy. Apart from PSA analysis, deoxythymidine kinase (dTK) analyses were also performed in an attempt to discover whether the latter could provide additional information about the tumor load in the different patient categories, viz. those with lymph node involvement (group 1), those with lymph node involvement but without distant metastases (group 2), and those with disseminated disease (group 3). The median PSA and dTK values in groups 1-3 were 6.5 micrograms/L and 2.7 U/microliter, 16 micrograms/L and 2.6 U/microL, and 90 micrograms/L and 7.8 U/microL, respectively. If the two analyses were used concomitantly, they could differentiate true localized disease from metastatic in approximately 92% of cases. The combination should prove of value in the primary assessment of a patient with a newly diagnosed prostatic adenocarcinoma.

The management of bilateral ureteric obstruction and renal failure in advanced prostate cancer

OBJECTIVES

To investigate the effect of upper tract decompression on the prognosis of uraemia secondary to bilateral ureteric obstruction in prostate cancer, with particular reference to the hormone dependency of the tumour.

PATIENTS AND METHODS

Prospectively collected data, over the period 1978-1993, were selected from the departmental database and from hospital case code data. Inclusion criteria were: blood urea > or = 15 mM, radiological evidence of bilateral ureteric obstruction, a histological diagnosis of prostate cancer, and the exclusion of out-flow tract obstruction. Of the 820 patients recorded in the departmental database, 27 (3.3%) fulfilled the criteria. Thirty-six patients were identified in total. Statistical analysis was by the Mann-Whitney non-parametric test.

RESULTS

Of the 36 patients with bilateral ureteric obstruction and renal failure, in those in whom androgen depletion had been undertaken after ureteric obstruction (i.e. androgen depletion was a treatment option), the mean survival was 646 days (n = 12, SD = 786). Among these patients upper tract decompression improved survival and reduced the amount of time patients spent in hospital. In those in whom androgen depletion had been carried out before obstruction (i.e. the tumour had escaped from hormonal control), survival was significantly worse (80 days, n = 24, SD = 86.8, P < 0.01). In this group the use of decompression improved survival little. Percutaneous nephrostomy was the commonest means of decompression (nephrostomy, 9; stent, 5; ureteroneocystostomy, 2).

DISCUSSION

In patients for whom hormonal therapy remains an option, upper tract decompression offers a worthwhile improvement in terms of increased survival and reduced in-patient time. However, if ureteric obstruction is diagnosed after hormone manipulation has been used, upper tract decompression has little effect on survival and should only be used in exceptional circumstances.

Correlative imaging with monoclonal antibodies in colorectal, ovarian, and prostate cancer

Monoclonal antibody (MoAb) imaging has contributed greatly to the diagnosis and staging of both colorectal and ovarian cancers, and recently has been tested in patients with prostate cancer. Anatomic imaging modalities such as computed tomography, ultrasound, and magnetic resonance imaging have deficiencies in imaging each of these cancers that can be complemented or overcome by using radioimmunoscintigraphy. The management of patients with colorectal cancer, in particular, has been aided by developments in immunoscintigraphy. The new, safe, and easy-to-prepare MoAbs make possible an effective form of colon and rectal cancer imaging that has been used for (1) staging primary colorectal tumors in presurgical patients, (2) determining extent of disease, (3) continuing surveillance of patients at risk for recurrence of disease, (4) managing patients with elevated carcinoembryonic antigen levels (even those with otherwise negative workup results), and (5) imaging for occult, disease in patients both before and after surgery. In ovarian cancer patients, MoAbs are promising as safe, sensitive imaging tools. The U.S. Food and Drug Administration has approved 111In satumomab pendetide (OncoScint CR/OV; Cytogen Corporation, Princeton, NJ) for use in imaging colorectal and ovarian cancer. Immunoscintigraphy is being refined and tested to locate bony and soft-tissue metastases in patients with prostate cancer. As both a complementary tool and, in some cases, the imaging modality of choice, MoAbs have proven to be safe, accurate imaging tools for many patients with cancer.

Patterns of lymphatic spread in thoracic esophageal cancer

BACKGROUND

The cervical nodes have been excluded from the category of regional nodes in cases of thoracic esophageal cancer in the present TNM classifications.

METHODS

One hundred and forty-one patients with thoracic esophageal cancer who had undergone extensive radical lymphadenectomy were included in the study. The patterns of early lymph node metastasis from the disease, in terms of lymph node metastases from the intramural tumors or those found in patients with a single metastatic node, were studied. Prognostic significance of the removal of the positive nodes also was examined in relation to the metastatic sites.

RESULTS

Of the 47 patients with intramural cancer, only 21% had nodal metastases confined to the mediastinum, 11% had positive cervical nodes, and 23% had jumping metastases to the extramediastinal nodes. Of the 31 patients with a single metastatic node, 61% showed metastasis in a jumping fashion, and 19% had a positive node in the neck. Seventy-four (79.6%) of the 93 patients with vessel invasion also had lymph node metastases, whereas 20 (41.7%) of the 48 patients without vessel invasion had metastases to the lymph nodes (P < 0.001). The 5-year projected survival rate for patients with positive cervical nodes was 27%, with no significant difference in survival rate compared with that for patients with metastatic nodes in the mediastinum or the abdomen. The number of involved nodes was related significantly to outcome: The 5-year survival rates for the 45 patients with negative nodes the 66 patients with one to four positive nodes were 71.8 and 34.2%, respectively (P < 0.01), whereas none of the 27 patients with five or more positive nodes survived more than 3 years after the operation (P < 0.001).

CONCLUSIONS

The cervical nodes should be included in the category of regional nodes in cases of thoracic esophageal cancer on the basis of the patterns of early lymph node metastases and the prognostic significance of a lymphadenectomy for metastases to these nodes.