Acid phosphatase levels in bone marrow: value in detecting early bone metastasis from carcinoma of the prostate

Bone marrow metastases. A review

Although bone marrow examination is a common procedure in the evaluation of patients with cancer, its role and contribution have been questioned in recent years. This review deals with the clinical and biologic aspects of metastasis to the bone marrow. The discussion is focused on the common tumor types that involve marrow and the application of newer techniques for tumor detection in the marrow. Therapeutic and prognostic implications of bone marrow metastasis are significant in several clinical settings. The mechanisms by which tumor cells affect marrow function have not been completely defined.

Leukaemic peripheral blood plasma and bone marrow plasma: comparison of influence on lymphocyte proliferation

Peripheral blood plasma from some children with untreated acute lymphoblastic leukaemia (ALL) exerted an inhibitory effect in vitro on phytohaemagglutinin-induced lymphocyte transformation of normal peripheral blood lymphocytes. This occurred at concentrations beyond that required for optimal response as judged by reduction of blast cell formation and tritiated thymidine and tritiated uridine incorporation into DNA and RNA, respectively. In contrast, bone marrow plasma from these patients was non-inhibitory or contained significantly less inhibitory activity. Bone marrow plasma from the majority of healthy controls was superior to their peripheral blood plasma in enhancing phytohaemagglutinin-induced mitogenesis. The difference between an individual's bone marrow- and peripheral blood-derived plasma in enhancing proliferation of patient and healthy control cells was significantly greater amongst the patients than the healthy control group; this was attributed mainly to the increased inhibitory activity of ALL peripheral blood plasma compared with normal plasma. Medium conditioned by phytohaemagglutinin-stimulated normal peripheral blood lymphocytes was effective in neutralizing the inhibitory activity of ALL peripheral blood plasma. Taken together, these in vitro results are at least suggestive that in vivo, in healthy subjects, the rapidly proliferating cells in the bone marrow and the 'resting' blood cells in the circulation may be under the influence of a fine balance of different types and/or levels of humoral growth stimulatory and inhibitory factors and that in ALL an unstable balance of these factors exists. The decreased proliferation of circulating blast cells compared with bone marrow blasts in ALL may be attributed, at least in part, to exposure to the different levels of inhibitor(s) in the circulation and bone marrow as demonstrated in vitro by our results.

Immunohistologic detection of prostate cancer pelvic lymph node micrometastases: correlation to preoperative serum prostate-specific antigen

OBJECTIVE

To test the hypothesis that prostate cancer lymph node (LN) micrometastases, undetected by standard histology, might be found using sensitive immunohistologic methods and may correlate to preoperative prostate-specific antigen (PSA) levels.

METHOD

Archival paraffin blocks of pelvic lymphadenectomy specimens from radical prostatectomy were blindly submitted for immunostaining using pan-cytokeratin monoclonal antibody SB-3, as well as antibodies directed against PSA. Automated immunostaining was performed on a Ventana Medical Systems 320 immunostainer. As a positive control, 7 cases with known nodal metastases by standard histology were blindly analyzed and all has detectable micrometastases by this methodology.

RESULTS

For 13 patients with PSA < 10.1 (8%) had LN micrometastases detected. For 10 patients with PSA between 10 and 20 and for 9 patients with PSA > 20, no occult metastases were detected. We did find previously undetected prostate cancer (CaP) LN micrometastases in 1 of 32 (3%) clinically localized prostate cancer patients who had undergone radical prostatectomy. In many LNs, cytokeratin stains cross-reacted and stained individual plasma cells, whereas in the positive metastatic case, a cluster/nest of CaP cells were reactive. To the unfamiliar observer, the pitfall of false-positive results because of nonspecific cytokeratin staining must be considered. These results are in exact agreement with another recent study which also found only a 3 percent incidence of unsuspected pelvic lymph node micrometastases in clinically localized CaP utilizing similar methods.

CONCLUSIONS

Our hypothesis was not substantiated: LN micrometastases were uncommon and did not correlate to serum PSA. Unlike studies with breast cancer, occult micrometastatic nodal disease not appreciated by standard methods appears to be uncommon in clinically localized prostatic carcinoma.

Bone marrow prostatic specific antigen and prostatic acid phosphatase levels: are they helpful in staging prostatic cancer?

We analyzed serum and bone marrow levels of prostatic specific antigen and prostatic acid phosphatase quantified by double antibody radioimmunoassay in 70 patients. Of the patients 36 had prostatic cancer, including 23 with metastatic disease. There was a significant correlation between the serum and bone marrow levels of prostatic specific antigen and prostatic acid phosphatase independently of the metastases (p less than 0.001). No patient with prostatic cancer and positive bone marrow prostatic specific antigen or prostatic acid phosphatase levels had normal serum levels. Quantification of bone marrow prostatic specific antigen and prostatic acid phosphatase does not provide more information than does serum determination.

Tumor markers: value and limitations in the management of cancer patients

Sixteen tumor markers are reviewed, and measured to the ideal: produced by the tumor cell alone absent in health and in benign disease present in all patients with a given malignancy level in the blood representative of tumor mass detectable in occult disease. The only marker that approaches the ideal is human chorionic gonadotropin (HCG) in gestational trophoblastic tumors. In this malignancy, the HCG level suggests the diagnosis and stage, confirms response to therapy, and predicts relapse. The three most widely used and intensely studied tumor markers are carcinoembryonic antigen (CEA), alphafetoprotein (AFP), and HCG. CEA cannot be used in screening for cancer, but in carcinoma of the colon its elevation preoperatively increases the likelihood of advanced disease and postoperative recurrence. Postoperatively, elevated titers are often but not invariably associated with recurrent disease. AFP and HCG are useful in the management of nonseminomatous germ cell testicular tumors. Like CEA, they cannot be used for screening. They are more likely to be increased with advancing stage, and after therapy rising levels almost always mean recurrent disease. Some markers are valuable in specific circumstances, such as calcitonin in screening for familial medullary carcinoma of the thyroid. In multiple myeloma, immunoglobulins are useful in determining the tumor mass and response to therapy. In neuroblastoma, catecholamine metabolites are useful primarily in making the diagnosis. In some malignancies, the absence of effective therapy lowers the value of the marker, as for AFP in hepatoma. The remaining markers are too unreliable or too little studied to be useful in the management of an individual patient with cancer. The purpose of this paper is to provide the clinician with an understanding of the limitations of the present tumor markers that will lead to wiser use of the tests, and to provide standards to which future tumor markers should be measured.

Acid phosphatase in prostatic tissue homogenates from patients with benign prostatic hyperplasia and prostatic carcinoma

Acid phosphatase activity biochemically in the primary tumor of 20 patients with prostatic carcinoma, was studied in an attempt to understand the basis for a correlation or lack of correlation between serum and/or bone marrow acid phosphatase levels and the presence and/or clinical behavior of prostatic carcinoma. The enzyme activity was similarly measured in 19 patients with benign prostatic hyperplasia as controls. On the average, enzyme activities were lower (P less than 0.002) in the tissues from patients with carcinoma. There was no correlation of enzyme activity in tumor with the age of the patient, stage of disease, degree of differentiation of the tumor, or serum acid phosphatase activity.

Bone marrow acid phosphatase by radioimmunoassay: 3 years of experience

Clinical followup of 112 patients staged by the immunochemical determination of prostatic acid phosphatase from bone marrow aspirates is presented. This represents a 94 per cent (112 of 118) retrieval rate of a group studied more than 2 years previously. Of the 11 patients judged to be at high risk 4 (36 per cent) have suffered bony metastases, whereas only 3 of 86 patients (3 per cent) with normal bone marrow acid phosphatase by radioimmunoassay have done so. An additional 184 patients with carcinoma and 77 controls have been studied. Although radioimmunoassay greatly improves specificity in bone marrow aspirates a few falsely positive results can occur. This finding may be secondary to cross reaction from leukocyte acid phosphatase and/or interference from lipid.

Immunological detection of metastases from prostatic adenocarcinoma

In six patients with known prostatic adenocarcinoma, extraprostatic (metastatic) tumor was suspected on radiographic or radionucleotide studies. When cytological examination of tissue obtained by needle aspiration or biopsy was nondiagnostic, radial gel immunodiffusion was used to identify the presence of prostatic acid phosphatase in the tissue. Four specimens demonstrated prostate-specific acid phosphatase activity, permitting the diagnosis of metastatic prostatic adenocarcinoma. The technique is simple and highly specific.

Tissue acid and alkaline phosphatase in prostatic carcinoma

Twenty-eight patients admitted with infravesical obstruction symptoms were studied. Fourteen of these patients were suffering from prostatic carcinoma defined as inoperable. The remaining 14 patients were diagnosed as benign prostatic hyperplasia (BPH) and transurethral resection (TUR) was performed to all of them. Specimens obtained by TUR were used to analyze tissue activities of total and tartarate labil acid phosphatase, and alkaline phosphatase. Enzymatic levels in the tissue were estimated by using fluorimetric method (FU/mg). The estimated averages seemed to vary in favor of the malignant tissue, however this variation was not found to be statistically significant. Different inhibition levels were observed in benign and malignant tissue with the addition of L(+) tartarate. The average levels of the alkaline phosphatase were found to be lower than those of acid phosphatase, but the former showed no difference between the malignant and benign groups.

Bone marrow acid phosphatase in prostate cancer: an assessment by immunoassay and biochemical methods

Comparisons of the bone marrow and serum acid phosphatase values obtained by counter-immunelectrophoresis and the Roy biochemical test were made in 72 patients with and in 13 patients without prostatic cancer. The counter-immunoelectophoresis test, when positive at more than 1 international unit per liter, showed only 4.4 per cent falsely positive results. The Roy biochemical test, which used sodium thymolphthalein monophosphate as the substrate, had 65 per cent falsely positive bone marrow acid phosphatase levels. Conflicting reports regarding the value of bone marrow acid phosphatase determinations in patients with prostatic cancer result from the use of non-specific substrates in biochemical methods for measurement and from the trauma incidental to bone marrow aspiration, which releases many non-prostatic acid phosphatase enzymes. The use of immunoassay such as counter-immunoelectrophoresis minimizes this source of error.

Radioimmunoassay of bone marrow prostatic acid phosphatase

The clinical value of prostate acid phosphatase (PAP) measurements in the bone marrow aspirate of patients with prostatic adenocarcinoma has been unclear. Using a radioimmunoassay (RIA) to measure PAP, we have evaluated this potential indicator of occult metastases in 127 controls and in 300 patients with prostatic adenocarcinoma. Elevations of the tumor marker were found in 9%, 10%, 19%, and 82% of patients with stages B, C, D1, and D2 adenocarcinoma respectively. Clinical follow-up ranging from 7 to 43 months (average 23 months) was available for 97 patients without any initial indication of metastasis by bone scan. In this group 11 patients had elevated levels of bone marrow acid phosphatase (BMAP) by RIA and four developed radiological evidence of bone metastasis 21-25 months following initial staging. However, only three of the 86 patients with normal BMAP levels have developed bone metastasis. Our results indicate that measurement of bone marrow PAP by immunological methods has prognostic significance. Dilution of the bone marrow aspirate by peripheral blood, however, may limit the application of this technique.

Clinical significance of serum and bone marrow acid phosphatase

Currently available immunochemical assays for the determination of serum prostatic acid phosphatase have improved the reliability of this biological marker in carcinoma of the prostate. Although the value of such methods for screening the general population is questionable, a certain percentage of elevated serum levels is observed in patients with localized disease. The significance of such findings is unclear at the present time. Recent evidence suggests that in elevated bone marrow acid phosphatase, using these methods is of predictive value in the future development of metastatic disease.

Radiation therapy as definitive treatment for localized carcinoma of prostate

A progress report on the treatment of 116 patients with adenocarcinoma of the prostate treated by external irradiation is presented. Fifteen, 60, and 41 patients presented initially with Stages A, B, and C, respectively. The majority of the patients received 7,000-7,500 rads during a period of seven to eight weeks, locally to the prostate gland. The five-year actuarial survival were 90, 70, and 40 per cent for Stages A, B, and C, respectively. The five-year survival rates for patients with well and moderately differentiated tumors were significantly better (45 per cent) than for those with poorly differentiated tumors (24 per cent). The five-year survival rate in the patients who received prior or concomitant hormone manipulation was lower (33 per cent) as compared with those receiving radiation therapy alone (43 per cent). All of the above differences were statistically significant (0.01 level). Of the patients failing, distant metastases have developed in 88 per cent suggesting that subclinical distant metastases might have been present prior to initiation of radiotherapy. The local control rate was 82 per cent. The morbidity of this mode of therapy was found to be acceptable. Radical radiation therapy is an effective method for control of carcinoma of the prostate and is potentially curative.

Carcinoma of gallbladder simulating metastatic prostatic cancer

This is a case of carcinoma of the gallbladder, which clinically, chemically, and radiographically simulated metastatic prostate cancer. Other causes of elevated serum and bone marrow acid phosphatase and axial skeletal osteoblastic metastases are reviewed.

Acid phosphatase: new developments

Acid phosphatase was the first "tumor marker" to be measured in the blood, and over 40 years have passed since an elevation of the serum acid phosphatase level was observed in patients with prostatic carcinoma. However, significant elevations in the level of this enzyme have been observed in other diseases, as well as elevations of other tissue phosphatases. Many improvements in the colorimetric technique have been introduced, but none has been used successfully to detect the tissue origin of this ubiquitous enzyme. The finding that prostatic acid phosphatase is antigenically distinct from acid phosphatase of other tissues opened a new horizon in the measurement of acid phosphatase in prostatic cancer. On the basis of this immunochemical specificity, several immunoassays have been employed for determining the prostatic acid phosphatase level.

Reliability of bone marrow acid phosphatase as a parameter of metastatic prostatic cancer

The reliability of bone marrow acid phosphatase determination by a spectrophotometric assay and 2 immunochemical methods was evaluated in 40 patients: 20 men with known prostatic carcinoma and 20 men of comparable age without clinical evidence of prostatic cancer. The large percentage of falsely positive results obtained by the colorimetric assay invalidates this method as the sole parameter of metastatic prostatic carcinoma.

An objective look at acid phosphatase determinations: a comparison of biochemical and immunological methods

Measurements of serum and bone marrow acid phosphatase were made by 3 enzymatic methods, alpha-naphthyl phosphate, beta-glycerol phosphate, and thymolphthalein monophosphate, and ocmpared to a double antibody radioimmunoassay. Serum and bone marrow acid phosphatase levels were studied in 46 controls with histologically proven benign prostatic hyperplasia and in 135 patients with various stages of prostatic carcinoma. In the control group the upper limit for bone marrow acid phosphatase was found to be significantly higher than the corresponding serum limit with respect to the enzymatic assays studied. The radioimmunoassay was the only method suitable for the analysis of the prostatic acid phosphatase content of bone marrow. A larger number of elevations were noted in patients with extracapsular and metastatic disease when prostatic acid phosphatase measurement was carried out by radioimmunoassay as compared to enzymatic methods. However, only 8% of the patients with intracapsular disease had elevations of prostatic acid phosphatase as measured by radioimmunoassay. Additional standardisation of immunological methods and clinical trials is required before comparison can be made of results from various centres using immunological methods for the measurement of prostatic acid phosphatase and a true assessment made of the usefulness of this procedure.

Prostatic acid phosphatase by radioimmunoassay tumor marker in bone marrow

Bone marrow acid phosphatase was determined by radioimmunoassay and enzymatic analysis in 95 patients with benign prostatic hypertrophy, 50 patients with disseminated prostatic carcinoma and 36 patients with non-prostatic malignancy. The results indicate superior specificity of the radioimmunoassay. A brief review of the topic and the clinical implications are discussed.

Clinical enzymology 2. Test strategies and interpretation of results

The greatest usefulness of enzyme determinations is in diagnosis and management of hepatic, cardiac, pancreatic, and skeletal muscle diseases. They occasionally are useful in patients with malignant or hematologic conditions. As a rule, enzyme determinations are sensitive enough for normal values to exclude disease but are too nonspecific for abnormal values to confirm disease. Exceptions to this rule are determination of the MB isoenzyme of creatine kinase, the flipped lactate dehydrogenase isoenzyme pattern, and calculation of the ratio of amylase clearance to creatinine clearance.

Bone marrow acid phosphatase in staging of prostatic cancer: how reliable is it?

To evaluate the reliability of bone marrow acid phosphatase in the staging of prostatic carcinoma we analyzed 50 bone marrow samples collected at random from the hematology service at this hospital. The samples were assayed for acid phosphatase content by a colorimetric method using sodium thymolphthalein monophosphate as a substrate and by 2 immunochemical assays developed at our laboratory (counter immunoelectrophoresis and radioimmunoassay). We found a high percentage (61 per cent) of falsely positive results in patients with various hematological diseases without evidence of prostatic carcinoma by the colorimetric evaluation. All of these patients except 1 had negative immunochemical assay. Until a specific assay for prostatic acid phosphatase is developed for clinical use we caution the use of a single elevation of bone marrow acid phosphatase as a parameter of metastatic disease.

Bone marrow acid phosphatase by radioimmunoassay

A double-antibody radioimmunoassay was developed and utilized to measure prostatic acid phosphatase in bone marrow aspirates. One hundred-eighteen patients with carcinoma of the prostate in various clinical stages, and fifty with benign prostatic hyperplasia were studied. In patients with carcinoma, levels of prostatic acid phosphatase in bone marrow aspirates were found to correlate well with increasing clinical stage of the disease. Determination of bone marrow prostatic acid phosphatase by radioimmunoassay may be a valuable adjunct to clinicopathologic staging of prostatic carcinoma.

The significance of bone marrow acid phosphatase in patients with prostatic carcinoma

The levels of total and l-tartrate labile acid phosphatase were studied in 49 patients with prostatic carcinoma. The results were compared with the results from a control group. The acid phosphatase levels from the bone marrow were above the upper normal limit of serum acid phosphatase both in the control group and in patients with prostatic carcinoma. This may be due to acid phosphatase released from blood cells during haemolysis. There was a positive correlation between serum and bone marrow acid phosphatase levels in patients with prostatic carcinoma. Significantly raised levels of bone marrow acid phosphatase (above the upper limit of the normal range from the control group) were observed only in advanced stage IV patients with significantly increased serum levels. The levels of bone marrow acid phosphatase gave no supplementary diagnostic information in any of the patients with prostatic carcinoma. Doubt is expressed concerning the hypothesis that raised levels of bone marrow acid phosphatase are diagnostic of early metastases from prostatic carcinoma.

The role of bone scanning in the assessment of prostatic carcinoma

Fifty new cases of carcinoma of the prostate were assessed prior to treatment to determine the incidence of bony metastases. The radioisotope bone scan was the most sensitive method of detecting metastases and of localising them. It was twice as accurate as the serum acid phosphatase estimation. Skeletal X-rays were the least accurate method. Forty-six per cent of patients had abnormal bone scans at presentation. The histological grade of the tumour correlated well with the bone scan. The higher the grade, the more likely was the bone scan to be abnormal. There is need for greater accuracy in detecting metastases, and the bone marrow acid phosphatase estimation, either alone or in conjunction with the bone scan, may provide this accuracy.

Lack of usefulness of bone marrow enzymes and calcium in staging patients with prostatic cancer

Bone marrow acid phosphatase has been reported to be a sensitive indicator of early bony metastasis from adenocarcinoma of the prostate. In order to evaluate this hypothesis, we measured bone marrow acid and alkaline phosphatase, lactic dehydrogenase, and calcium levels in a group of 84 patients with a variety of problems, including 18 with cancer of the prostate. We found that the bone marrow acid and alkaline phosphatase and lactic dehydrogenase were elevated and calcium was depressed in most patients. Among patients with prostate cancer, bone marrow acid phosphatase was not significantly different between those with or without bone metastases. In addition, the patients with prostatic cancer did not have higher levels of bone marrow acid phosphatase than subjects with other malignant and nonmalignant conditions. The level of acid and alkaline phosphatase, lactic dehydrogenase and calcium varied predictably with the aspiration technique used and was independent of sex, disease state or method of chemical determination. Due to this variation, we believe that bone marrow enzyme and calcium levels are of no value in the detection of metastases in patients with prostate cancer.

Radioimmunochemical measurement of bone marrow prostatic acid phosphatase

Human acid phosphatases are ubiquitous phosphohydrolases that are present in most respiring tissues and cells. Specifically, human prostatic acid phosphatase is a unique enzyme within a vast family of acid phosphatases concerned with catabolic processes in cellular metabolism. The majority of serum and bone marrow acid phosphatases are of non-prostatic origin and are present chiefly in erythrocytes, leukocytes, platelets and other maturing cells in the bone marrow. The specific concentration of prostatic acid phosphatase in serum and bone marrow is normally relatively low compared to non-prostatic acid phosphatases. Many falsely positive assays for total serum acid phosphatases and bone marrow acid phosphatases have been reported, particularly after traumatic marrow biopsy procedures and mishandling of blood samples in the clinical laboratory and in hematologic disease states. The disruption and lysis of whole blood and marrow cells can liberate non-specific acid phosphatases into the serum. Since standard enzymatic assays do not discriminate accurately prostatic acid phosphatase from non-prostatic acid phosphatase present in the serum spurious results can be realized. A preliminary experience with a promising radioimmunoassay for the specific measurement of prostatic acid phosphatase in bone marrow and serum is presented.

Early stage prostatic cancer investigated by pelvic lymph node biopsy and bone marrow acid phosphatase

A prospective study was done to evaluate 47 patients with early stage prostatic cancer. Pelvic lymphadenectomy was combined with bone marrow acid phosphatase determination to evaluate early metastatic disease. Thirteen patients (28 per cent) had tumor in the pelvic lymph nodes. In no instance was the bone marrow acid phosphatase elevated to more than the normal value for serum by the substrate used. Combined high grade and stage tumors seemed to have an increased incidence of metastases to pelvic lymph nodes. A surprisingly high incidence of B1 lesions (5 of 21 patients or 24 per cent) had positive lymph nodes. Generally, the nodes were moderately well or well differentiated lesions. The metastases were unilateral, frequently microscopic only and involved 1 or only a few nodes. Pelvic lymphadenectomy seems to have a well defined role in the diagnostic study of early stage prostatic cancer, while bone marrow acid phosphatase determinations were of no value.

Elevated bone marrow acid phosphatase: the problem of false positives

Bone marrow acid phosphatase values were studied in 24 patients (12 men and 12 women) selected at random, including 6 at autopsy. False positive results were noted in 8 of the 18 patients who were alive and in all 6 patients studied at autopsy. The possible causes for these falsely elevated results are discussed. The bone marrow acid phosphatase is a test of poor specificity and should not be used as the sole test on which vital decisions regarding management of the patient are based.

Recent progress in ultrasonography of the bladder and prostate

Gray scale transrectal ultrasonography has proved to be a valuable adjunct in the evaluation of patients with tumors of the prostate and bladder. Its application in patients with prostatic disease is in the detection of early asymptomatic tumors, in the accurate staging of local disease and in the following of patients after the institution of specific treatment. Although it is not being used for the detection of bladder tumors the procedure is a reliable means to evaluate the degree of tumor invasion so that proper therapy can be instituted.

Carcinoma of the prostate: a critical look at staging

To stage accurately the extent of the disease comprehensive investigations were done on 75 patients with histologically documented carcinoma of the prostate. Estimation of bone marrow acid phosphatase appears to be the most sensitive test to detect blood-borne metastases. Serum acid phosphatase appears to be of little value in the detection of early blood spread and may have a role only in monitoring the effect of treatment on advanced disease. Bone scanning with technetium compounds has the disadvantage of non-specificity but has far greater sensitivity than a skeletal survey. Bone marrow cytology was not rewarding in the detection of early metastatic disease. Pedal lymphangiography is a highly inaccurate method to detect lymphatic spread of carcinoma of the prostate and pelvic lymphadenectomy, when indicated, remains the only truly adequate method to assess lymph node involvement. There was a 37 per cent incidence of metastatic lymph node pathology in 30 patients undergoing this procedure before either radical prostatectomy or deep x-ray therapy. A close correlation was found between stage and grade of disease and incidence of nodal pathology. There was some correlation between degree of nodal involvement and evidence of blood spread as detected by elevated bone marrow acid phosphatase levels. The significance of this finding remains unclear.

Radical retropubic prostatectomy for cancer: a 20-year experience

A review of 159 patients treated by radical retropubic prostatovesiculectomy from 1951 through 1970 has reinforced our belief that this is a satisfactory method of treatment for prostatic cancer confined to the prostate. A 10-year survival of 55 per cent and a 15-year survival of 45 per cent compare well to the results reported for perineal prostatectomy. The postoperative mortality rate was 2.5 per cent and total incontinence was 12.5 per cent after radical retropubic prostatectomy. Completely normal voiding occurred in 108 of the 159 patients. Stress incontinence but no need for an incontinence device occurred in 31 patients. Improved methods for preoperative staging of the disease give promise for even higher cure rates in the future.

Bone marrow acid phosphatase: another look

Recent reports have indicated that bone marrow acid phosphatase is the most sensitive test in detecting bony metastases. The experience reported herein suggests that falsely positive results may be common, especially in patients with primary hematologic disorders. A plea is made that caution be given to the interpretation of this test so that some patients will not be denied appropriate therapy and the role of bone marrow acid phosphatase can be better defined by long-term followup in such patients.

Bone marrow acid phosphatase: prognostic value in patients undergoing radical prostatectomy

Preoperative bone marrow acid phosphatase determinations were elevated in 18 of 31 patients who underwent radical prostatectomies. A review of the surgical pathology and clinical followup demonstrated a higher incidence of metastasis in these patients.

Enzymes in peripheral and bone marrow serum in patients with cancer

Lactic dehydrogenase (LDH), glutamic-oxalacetic transaminase (GOT), and acid and alkaline phosphatase activities in bone marrow and in cubital vein serum were compared. For patients without cancer, marrow serum LDH attained levels four times as high, and GOT and alkaline phosphatase, levels twice as high as those normal for cubital vein serum; levels of acid phosphatase were the same for both sources. For patients with cancer, significant increase of enzyme levels over reference levels depends on the tumor origin and on the presence and localization of metastases. Marrow enzyme levels may become elevated with or without concurrent elevation in cubital vein serum. Concurrent elevations were found with colonic carcinoma and lymphoid leukemia, and noncurrent elevations, with prostatic cancer, myeloid leukemia, and myeloma. A nonconcurrent elevation of marrow enzymes indicates that the origin of the enzyme is in the marrow, whereas with concurrent elevation, the source of the enzyme may be another organ.

"Positive" bone scan--a contraindication to surgery?

Eleven patients with urologic cancer had an abnormal 99mTc (technetium-99m) bone scan as the sole evidence of metastatic disease. Potentially curative therapy should not be withheld on the basis of a "positive" bone scan if such an area is accessible to selected bone biopsy and proves to be negative for tumor histologically.

Bone marrow acid phosphatase in staging prostatic carcinoma

We evaluated bone marrow acid phosphatase in 30 patients as another parameter in staging prostatic carcinoma. This method is reliable and useful as part of the staging precedures. No falsely positive results were found and the procedure provided the only indication of metastatic diseases in 4 cases.

Serial Fluorine-18 bone scans in the follow-up of carcinoma of the prostate

74 patients with prostatic cancer were studied annually by combined radiological and fluorine-18 scan survey over a 5-year period. The results of the long term follow-up of bone cans is reported. At the time of the initial diagnosis 71-5% of the patients had advanced disease and 56% had radiological or scan evidence of metastases. A critical evaluation of the scans resulted in the detection of early bone lesions in 25% of patients with no radiological evidence of metastases. Follow-up of these patients has shown that scan abnormalities preceded radiological changes from between 1 to 4 years and there was good correlation proven histologically by bone biopsy or autopsy in more than half of the patients. In patients with a positive bone scan and positive X-rays the scan abnormalities were more extensive than the corresponding X-ray lesions. When bone healing occurred with endocrine treatment this was more readily apparent on the X-rays. False negative scans were not seen with fluorine-18 which allows for greater accuracy in the detection of skeletal metastases. Bone scanning has enabled correct staging to be carried out. This study confirms the high incidence of cardiac and vascular complications in patients treated with oestrogens.