Added Value of [18F]PSMA-1007 PET/CT and PET/MRI in Patients With Biochemically Recurrent Prostate Cancer: Impact on Detection Rates and Clinical Management

BACKGROUND

Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) can change management in a large fraction of patients with biochemically recurrent prostate cancer (BCR).

PURPOSE

To investigate the added value of PET to MRI and CT for this patient group, and to explore whether the choice of the PET paired modality (PET/MRI vs. PET/CT) impacts detection rates and clinical management.

STUDY TYPE

Retrospective.

SUBJECTS

41 patients with BCR (median age [range]: 68 [55-78]).

FIELD STRENGTH/SEQUENCE

3T, including T1-weighted gradient echo (GRE), T2-weighted turbo spin echo (TSE) and dynamic contrast-enhanced GRE sequences, diffusion-weighted echo-planar imaging, and a T1-weighted TSE spine sequence. In addition to MRI, [18F]PSMA-1007 PET and low-dose CT were acquired on the same day.

ASSESSMENT

Images were reported using a five-point Likert scale by two teams each consisting of a radiologist and a nuclear medicine physician. The radiologist performed a reading using CT and MRI data and a joint reading between radiologist and nuclear medicine physician was performed using MRI, CT, and PET from either PET/MRI or PET/CT. Findings were presented to an oncologist to create intended treatment plans. Intrareader and interreader agreement analysis was performed.

STATISTICAL TESTS

McNemar test, Cohen's κ, and intraclass correlation coefficients. A P-value <0.05 was considered significant.

RESULTS

7 patients had positive findings on MRI and CT, 22 patients on joint reading with PET/CT, and 18 patients joint reading with PET/MRI. For overall positivity, interreader agreement was poor for MR and CT (κ = 0.36) and almost perfect with addition of PET (PET/CT κ = 0.85, PET/MRI κ = 0.85). The addition of PET from PET/CT and PET/MRI changed intended treatment in 20 and 18 patients, respectively. Between joint readings, intended treatment was different for eight patients.

DATA CONCLUSION

The addition of [18F]PSMA-1007 PET/MRI or PET/CT to MRI and CT may increase detection rates, could reduce interreader variability, and may change intended treatment in half of patients with BCR.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 3.

Stability of metabolic tumor volume may enable radiotherapy dose painting in anal cancer

PURPOSE

To evaluate the variability of the 18F-FDG-PET/CT-based metabolic tumor volume (MTV) in anal cancers during fractionated chemoradiotherapy (CRT), and assess the impact of this variability on dosimetric accuracy in MTV-targeted dose painting.

METHODS

Eleven patients with anal squamous cell carcinoma who received fractionated chemoradiotherapy with curative intent were included. 18F-FDG PET/CT images were acquired at pre- and mid-treatment. Target volumes and organs at risk (OARs) were contoured manually on both image series. The MTV was generated from the PET images by thresholding. Treatment plans were retrospectively optimized for both image series using volumetric modulated arc therapy (VMAT). Standard plans prescribed 48.6 Gy, 54 Gy and 57.5 Gy in 27 fractions to elective regions, lymph node metastases and primary tumor, respectively. Dose painting plans included an extra dose level of 65 Gy to the MTV. Pre-treatment plans were transferred and re-calculated at mid-treatment basis.

RESULTS

MTV decreased from pre- to mid-treatment in 10 of the 11 patients. On average, 71 % of MTVmid overlapped with MTVpre. The median and mean doses to the MTV were robust against anatomical changes, but the transferred dose painting plans had lower D98% values than the original and re-optimized plans. No major differences were found between standard and dose painting plans for OARs.

CONCLUSIONS

Despite volumetric changes in the MTV, adequate dose coverage was observed in most dose painting plans. The findings indicate little or no need for adaptive dose painting at mid-treatment. Dose painting appears to be a safe treatment alternative with similar dose sparing of OARs.

Deep learning-based automatic delineation of anal cancer gross tumour volume: a multimodality comparison of CT, PET and MRI

BACKGROUND

Accurate target volume delineation is a prerequisite for high-precision radiotherapy. However, manual delineation is resource-demanding and prone to interobserver variation. An automatic delineation approach could potentially save time and increase delineation consistency. In this study, the applicability of deep learning for fully automatic delineation of the gross tumour volume (GTV) in patients with anal squamous cell carcinoma (ASCC) was evaluated for the first time. An extensive comparison of the effects single modality and multimodality combinations of computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) have on automatic delineation quality was conducted.

MATERIAL AND METHODS

18F-fluorodeoxyglucose PET/CT and contrast-enhanced CT (ceCT) images were collected for 86 patients with ASCC. A subset of 36 patients also underwent a study-specific 3T MRI examination including T2- and diffusion-weighted imaging. The resulting two datasets were analysed separately. A two-dimensional U-Net convolutional neural network (CNN) was trained to delineate the GTV in axial image slices based on single or multimodality image input. Manual GTV delineations constituted the ground truth for CNN model training and evaluation. Models were evaluated using the Dice similarity coefficient (Dice) and surface distance metrics computed from five-fold cross-validation.

RESULTS

CNN-generated automatic delineations demonstrated good agreement with the ground truth, resulting in mean Dice scores of 0.65-0.76 and 0.74-0.83 for the 86 and 36-patient datasets, respectively. For both datasets, the highest mean Dice scores were obtained using a multimodal combination of PET and ceCT (0.76-0.83). However, models based on single modality ceCT performed comparably well (0.74-0.81). T2W-only models performed acceptably but were somewhat inferior to the PET/ceCT and ceCT-based models.

CONCLUSION

CNNs provided high-quality automatic GTV delineations for both single and multimodality image input, indicating that deep learning may prove a versatile tool for target volume delineation in future patients with ASCC.

Localization of primary prostate cancer: FACBC PET/CT compared with multiparametric MRI using histopathology as reference standard

FACBC (anti-1-amino-3-¹⁸F-fluorocyclobutane-1-carboxylic acid) is a FDA-approved PET-tracer in patients with suspected recurrent prostate cancer. In the diagnostic work-up of primary prostate cancer, accurate localization of the index tumor is needed for image-guidance of biopsies. We therefore assessed the performance of FACBC PET/CT to detect and localize the index tumor and compared it to multiparametric MRI (mpMRI) using whole-mount histopathology as reference standard. Twenty-three patients with biopsy-proven prostate cancer had FACBC PET/CT and mpMRI within two weeks prior to prostatectomy. FACBC PET/CT was acquired as 14 minutes list-mode and re-binned into seven 2-minutes intervals. Static FACBC was the acquired data from 4-6 minutes, whereas the dynamic FACBC included all seven intervals. Two radiologists and two nuclear medicine physicians independently interpreted the images and consensus was reached in case of discrepancy. Static PET detected 15 of 23 (65%) of the index tumors, dynamic PET detected 14 of 22 (64%), and MRI detected 20 of 23 (87%). To assess the extent of the tumor, the interpreters delineated the tumor in a 12-regions sector-based template. True positive, true negative, false positive and false negative sectors were recorded based on the template drawings and whole-mount histopathology. Both static and dynamic FACBC PET had sensitivity of 40% and specificity of 99%, whereas MRI had sensitivity of 81% and specificity of 100%. Our data indicate that FACBC PET/CT may be useful but that mpMRI is better for localizing the index tumor in patients with prostate cancer.

Robotic salvage pelvic lymph node dissection for locoregional recurrence after radical prostatectomy: a single institution experience

OBJECTIVES

To assess treatment response (PSA < 0.2 ng/ml), need for additional therapy and complication rate after robot assisted salvage pelvic lymph node dissection (sPLND).

MATERIAL AND METHODS

Analysis of outcomes data from radical prostatectomy (RP) patients consecutively operated with robot assisted sPLND due to biochemical recurrence and positron-emission tomography (PET)/computed tomography (CT)-detected nodal recurrence of pelvic lymph nodes.

RESULTS

Sixty-nine patients underwent robotic sPLND after a median time of 47 months post- RP. Sixty-four patients (93%) had malignant lymph nodes upon histological assessment of sPLND specimen. Twenty patients (29%) achieved PSA < 0.2 ng/ml 6 weeks postoperatively. After median (IQR) follow-up of 15 months (10-27), fourteen patients (20%) still had PSA < 0.2 ng/ml without additional therapy and forty-one patients (59%) had started additional therapy. No significant predictor for treatment response was found. Postoperative complications occurred in 14 patients (20%). Eleven of these complications were classified as Clavien-Dindo grade 1.

CONCLUSION

Oncological benefit of sPLND as the only salvage procedure seems to be limited, though almost one third of patients achieved treatment response. Clinical trials are needed to determine if sPLND as part of a multimodal treatment may improve outcome.

Prostate-Specific Membrane Antigen PET for Assessment of Primary and Recurrent Prostate Cancer with Histopathology as Reference Standard: A Systematic Review and Meta-Analysis

Prostate-specific membrane antigen PET is a promising diagnostic tool in prostate cancer. The gold standard for the detection of prostate tumor and lymph node metastases is histopathology. The aim of the present review was to investigate accuracy measures of ⁶⁸Ga/¹⁸F-labeled prostate-specific membrane antigen PET tracers in primary and recurrent prostate cancer with systematic sector-based histopathology as the reference standard. A systematic literature search was performed and 34 studies were included. Overall, prostate-specific membrane antigen PET showed high specificity, but variable sensitivity to localize known prostate cancer and detect pelvic lymph node metastases.

18F-Fluciclovine PET for Assessment of Prostate Cancer with Histopathology as Reference Standard: A Systematic Review

The PET tracer ¹⁸F-fluciclovine (Axumin) was recently approved in the United States and Europe for men with suspected prostate cancer recurrence following prior treatment. This article summarizes studies where systematic sector-based histopathology was used as reference standard to assess the diagnostic accuracy of the tracer ¹⁸F-fluciclovine PET in patients with prostate cancer.

Metastatic-directed therapy using PSMA-PET/CT at PSA relapse

The side effects of androgen deprivation therapy (ADT) as general treatment against prostate cancer are known to impair quality of life. However, the optimal onset of ADT at PSA relapse is unknown, especially in patients with normal testosterone. In our case a limited PSMA avid lymph node was detected on PET/CT. Our case highlights the importance of metastasis-directed therapy balancing general versus tailored treatment in the decision making in the era of advanced molecular imaging. By using PSMA-PET/CT and radiation we were able to pinpoint the metastasis prolonging the ADT-free survival, thus sparing the patient the side-effects of continuous ADT.

Anal cancer chemoradiotherapy outcome prediction using 18F-fluorodeoxyglucose positron emission tomography and clinicopathological factors

OBJECTIVE

To assess the role of [¹⁸F]fluorodeoxyglucose (FDG) positron emission tomography (PET), obtained before and during chemoradiotherapy, in predicting locoregional failure relative to clinicopathological factors for patients with anal cancer.

METHODS

93 patients with anal squamous cell carcinoma treated with chemoradiotherapy were included in a prospective observational study (NCT01937780). FDG-PET/CT was performed for all patients before treatment, and for a subgroup (n = 39) also 2 weeks into treatment. FDG-PET was evaluated with standardized uptake values (SUV_{max/peak/mean}), metabolic tumor volume (MTV), total lesion glycolysis (TLG), and a proposed Z-normalized combination of MTV and SUV_peak (ZMP). The objective was to predict locoregional failure using FDG-PET, tumor and lymph node stage, gross tumor volume (GTV) and human papilloma virus (HPV) status in univariate and bivariate Cox regression analysis.

RESULTS

N3 lymph node stage, HPV negative tumor, GTV, MTV, TLG and ZMP were in univariate analysis significant predictors of locoregional failure (p < 0.01), while SUV_{max/peak/mean} were not (p > 0.2). In bivariate analysis HPV status was the most independent predictor in combinations with N3 stage, ZMP, TLG, and MTV (p < 0.02). The FDG-PET parameters at 2 weeks into radiotherapy decreased by 30-40 % of the initial values, but neither absolute nor relative decrease improved the prediction models.

CONCLUSION

Pre-treatment PET parameters are predictive of chemoradiotherapy outcome in anal cancer, although HPV negativity and N3 stage are the strongest single predictors. Predictions can be improved by combining HPV with PET parameters such as MTV, TLG or ZMP. PET 2 weeks into treatment does not provide added predictive value.

ADVANCES IN KNOWLEDGE

Pre-treatment PET parameters of anal cancer showed a predictive role independent of clinicopathological factors. Although the PET parameters show substantial reduction from pre- to mid-treatment, the changes were not predictive of chemoradiotherapy outcome.

Target volume delineation of anal cancer based on magnetic resonance imaging or positron emission tomography

Purpose

To compare target volume delineation of anal cancer using positron emission tomography (PET) and magnetic resonance imaging (MRI) with respect to inter-observer and inter-modality variability.

Methods

Nineteen patients with anal cancer undergoing chemoradiotherapy were prospectively included. Planning computed tomography (CT) images were co-registered with 18F–fluorodexocyglucose (FDG) PET/CT images and T2 and diffusion weighted (DW) MR images. Three oncologists delineated the Gross Tumor Volume (GTV) according to national guidelines and the visible tumor tissue (GTV_T). MRI and PET based delineations were evaluated by absolute volumes and Dice similarity coefficients.

Results

The median volume of the GTVs was 27 and 31 cm³ for PET and MRI, respectively, while it was 6 and 11 cm³ for GTV_T. Both GTV and GTV_T volumes were highly correlated between delineators (r = 0.90 and r = 0.96, respectively). The median Dice similarity coefficient was 0.75 when comparing the GTVs based on PET/CT (GTV_PET) with the GTVs based on MRI and CT (GTV_MRI). The median Dice coefficient was 0.56 when comparing the visible tumor volume evaluated by PET (GTV_{T_PET}) with the same volume evaluated by MRI (GTV_{T_MRI}). Margins of 1–2 mm in the axial plane and 7–8 mm in superoinferior direction were required for coverage of the individual observer’s GTVs.

Conclusions

The rather good agreement between PET- and MRI-based GTVs indicates that either modality may be used for standard target delineation of anal cancer. However, larger deviations were found for GTV_T, which may impact future tumor boost strategies.

Changes in prostate-specific antigen, markers of bone metabolism and bone scans after treatment with radium-223

OBJECTIVE

The aim of this study was to assess treatment-related changes in prostate-specific antigen (PSA), total and bone alkaline phosphatase (total ALP, bone ALP), and changes on conventional bone scans in patients with metastatic castration-resistant prostate cancer (mCRPC) with bone metastases who received six cycles of radium-223 (Ra-223).

MATERIALS AND METHODS

Changes in PSA, total ALP and bone ALP (≥30% increase or decrease), and changes on bone scans were assessed before and after six monthly cycles of Ra-223 therapy (50 kBq/kg body weight) in 14 patients with mCRPC with bone metastases and four patients on placebo.

RESULTS

Post-treatment PSA increased by at least 30% in 11 out of 14 patients and remained stable in three. Total ALP and bone ALP decreased in six and nine patients, respectively. In 10 out of 12 evaluable patients the uptake on post-treatment bone scan was reduced in lesions with high pretreatment uptake, in 11 patients accompanied by the development of new or expanded bone lesions. FACBC position emission tomography/computed tomography scans confirmed the growth of new or expanded bone metastases in two patients.

CONCLUSIONS

These observations support the notion that Ra-223 kills tumour cells in metastases surrounded by highly proliferating osteoblasts, consistent with the reported survival benefit. The radiation effect in small tumour deposits not surrounded by increased osteoblast activity seems, however, insufficient, thus allowing continuous tumour growth. Long-lasting PSA reductions are the exception rather than the rule during Ra-223 treatment, whereas alkaline phosphatases decrease more frequently. To improve the overall anticancer effect, Ra-223 might be a valuable component of combination treatment.

Treatment and 5-year survival in patients with nonmetastatic prostate cancer: the Norwegian experience

OBJECTIVE

To establish the 5-year overall and prostate cancer-specific survival in 3486 patients with a new diagnosis of nonmetastatic prostate cancer recorded in the Norwegian Prostate Cancer Registry in 2004-2005.

METHODS

The eligible patients were ≤75 years old and had undergone radical prostatectomy (n = 895), high-dose radiotherapy with or without adjuvant hormonal therapy (n = 1339), or no local treatment (n = 1252). Kaplan-Meier estimates, Cox regression analyses, and competing risk methods were used.

RESULTS

For all patients, the overall and prostate cancer-specific survival was 89.8% (95% confidence interval 88.8-90.8) and 96.5% (95% confidence interval 95.9-97.1), respectively. Less than 1% of the 76 deaths in patients with low-risk tumors were from prostate cancer. Among the patients with high-risk tumors in the no local treatment group, 48% of the 207 deaths were from prostate cancer compared with 33% of the 81 deaths in the radical prostatectomy and radiotherapy groups (P = .03). On multivariate analysis, local treatment (yes vs no), tumor risk category, and performance status were independently associated with prostate cancer survival, but age was not. No significant differences emerged between the radical prostatectomy and radiotherapy groups. A lack of local treatment and a reduced performance status were significantly associated with reduced prostate cancer-specific survival.

CONCLUSION

Although based on only 5 years of observation, we have concluded that patients with low-risk tumors should be informed about the option of active surveillance. Patients with high-risk tumors run a risk of undertreatment if local treatment is not applied. The correct identification of tumor risk categories and comorbidity at the diagnosis of nonmetastatic prostate cancer remains a challenge for clinicians.

A national study of adverse effects and global quality of life among candidates for curative treatment for prostate cancer

OBJECTIVES

To provide population-based estimates of typical adverse effects (AEs), e.g. urinary, bowel and sexual dysfunction, in patients with non-metastatic recurrence-free prostate cancer (PCa) by curative treatment method, including no treatment. To describe associations between typical AEs and global quality of life (QoL) and to study patients' use of medication for erectile dysfunction (EDmed) and the relationship between such use and global QoL.

PATIENTS AND METHODS

In October 2006 a national population-based sample of PCa survivors diagnosed in 2004 was invited to a postal survey focusing on treatment-related AEs and global QoL, 12-32 months after treatment start. All had completed their initial treatment. In the present study, 771 compliers were categorized into four groups of localized or locally advanced PCa related to the treatment they completed: (i) no treatment; (ii) radical prostatectomy (RP); (iii) radiotherapy (RAD) without hormones; and (iv) RAD with hormone therapy of 3-24 months duration. Measurement of AEs was restricted to function, using selected items from the 50-item Expanded Prostate Cancer Index Composite and the Brief Sexual Function Inventory among others, whereas global QoL was measured with the 12-item short-form health survey. National prescription data enabled assessment of adjuvant hormone application and EDmed use.

RESULTS

Men who had undergone RP reported more urinary incontinence (24%) than the other treatment groups, but had the lowest level of moderate/severe urinary irritative-obstructive symptoms. Men from the 'no treatment' group had the highest level of moderate/severe irritative-obstructive urinary symptoms. Men who had undergone RAD reported higher levels of irritative intestinal symptoms and faecal leakage compared with the RP group and the no treatment group. In all treatment groups, poor sexual drive and poor erectile function were common AEs, with men treated with RP reporting the highest prevalence of poor erectile function (89%). Presence of irritative-obstructive urinary symptoms and poor sexual drive were independently associated with low global QoL in multivariate analyses. Fifty percent of the study group had used EDmed after treatment start, but only 47% of them were still using EDmed at the time of the survey. Use of EDmed was not significantly associated with global QoL.

CONCLUSIONS

PCa survivors after curative treatment, but also patients without any anticancer therapy, report high levels of urinary and sexual AEs. Irritative-obstructive urinary symptoms and poor sexual drive were significantly associated with low global QoL, whereas erectile function and use of EDmed were not.

Fatigue in prostate cancer survivors treated with definitive radiotherapy and LHRH analogs

BACKGROUND

Few studies have dealt with chronic fatigue (CF) in definitive radiotherapy (RAD) patients during and after (neo-)adjuvant androgen deprivation therapy (ADT) for prostate cancer.

METHODS

CF was the primary outcome in this population-based cross-sectional study as evaluated by the Fatigue Questionnaire. We compared the post-RAD levels of fatigue in two groups of > or = 1 year prostate cancer survivors; those with ongoing medical castration (HTcont) and those who had used a luteinizing hormone-releasing hormone analog (LHRHa), but had discontinued the therapy at the time of the survey (HTdis). The prevalence of CF and the levels of total fatigue were compared to comparable parameters in men with prostatic RAD who never had had ADT (Control group) and to men > 60 years old from the general population.

RESULTS

After an observation time of median 18 months since start of radiotherapy about 40% of our > or = 1 year prostate cancer survivors from the HTcont group reported CF, as compared to approximately a quarter of men from the HTdis group and, the prevalence of CF in the latter group being similar to that of hormone-naïve RAD controls and males from the general population. After discontinuation of ADT, age 65 years or below was associated with increased risk of CF.

CONCLUSIONS

Pre-counseling of prostate cancer patients starting (neo-)adjuvant LHRHa therapy must include fatigue, mainly physical fatigue, in particular in men aged 65 years or younger. Future studies of testosterone recovery after ADT discontinuation should also include measures of CF.

Chronic fatigue in prostate cancer patients after radical prostatectomy (RP) or high-dose radiotherapy (RAD)

5164

Background: Chronic fatigue (CF) is frequent in cancer patients, but has been less studied in prostate cancer patients (PCPs). This study compares CF in PCPs treated with RP or RAD(≥70Gy), who have never received any hormonal therapy. Methods: In 2006 we addressed all Norwegian PCPs who had been diagnosed in 2004 and were alive (N = 2,997). Among the 2,194 PCPs (73%) responding we identified 332 patients with RP and 183 with RAD 12–32 months before our survey. The PCPs returned a mailed questionnaire covering fatigue, quality of life, urinary and bowel bother, sexual function, comorbidity, and lifestyle. Hormonal therapy identified by the national prescription database or self-report, lead to exclusion. Caseness of CF was based on the Fatigue Questionnaire. Results: Caseness of CF was observed in 13.6% of men with RP (95%CI 9.9–17.2%) and in 25.7% after RAD (95%CI 19.4–32.0%) (p = 0.001). The prevalence in the RP group was similar to the norm observed in Norwegian men >60 years. PCPs with RP or RAD had similar prevalence of bother regarding urinary symptoms (13 vs 16%, p = 0.13), while more RAD than RP patients reported bother due to bowel symptoms (24 vs 4%, p < 0.001). Sexual functioning showed a better score in the RAD versus the RP group (p < 0001). In multivariate regression analysis treatment modality did not show any significant association with CF (p = 0.25). In contrast, physical and mental quality of life (both p < 0.001) and bother due to bowel problems (p = 0.005) were associated with CF caseness. No significant associations were found between urinary bother, sexual function and CF caseness. Conclusions: This national study of PCP treated with curative intention showed a much higher prevalence of CF after RAD compared to RP. In multivariate analysis treatment modality was not significantly associated with CF caseness. Bowel bother was more common after RAD, and showed a significant association with CF caseness, however, with a wide confidence interval.

No significant financial relationships to disclose.

Association between serum 25(OH)D and death from prostate cancer

Based on observations that for certain cancers, mortality varies according to sun exposure, vitamin D has been proposed to influence on disease progression. This study aims to investigate whether serum levels of 25(OH)D are associated with prognosis in patients with prostate cancer. In total, 160 patients with a serum sample in the JANUS serum bank were included. For 123 patients a pre-treatment serum sample was taken, whereas 37 of the patients had received hormone therapy prior to the blood collection. The serum level of 25(OH)D was classified as low (<50 nmol l(-1)), medium (50-80 nmol l(-1)) or high (>80 nmol l(-1)). A Cox proportional hazard regression model was used to assess the association between serum 25(OH)D and cancer mortality. During follow-up, 61 deaths occurred, of whom 52 died of prostate cancer. The median time of follow-up was 44.0 months (range, 1.2-154.6). Serum 25(OH)D at medium or high levels were significantly related to better prognosis (RR 0.33; 95% CI 0.14-0.77, RR 0.16; 95% CI 0.05-0.43) compared with the low level. Analysis restricted to patients receiving hormone therapy gave a stronger association. The serum level of 25(OH)D may be involved in disease progression and is a potential marker of prognosis in patients with prostate cancer.

[Treatment of hormone-resistant prostate cancer]

Hormone-resistant prostate cancer is defined by disease progression despite of castration levels of serum testosterone. Due to a good palliative effect and low toxicity, radiotherapy is the cornerstone in treatment of painful bone metastases, the most frequent symptom of advanced hormone-resistant prostate cancer. Patients presenting with spinal cord compression should be assessed for decompressive surgery before radiotherapy. With local growth of prostate cancer and problems with urination, a transurethral resection may palliate symptoms. Postoperative radiotherapy should however be considered for these patients, so local regrowth of the tumour can be prevented. Taxan-based chemotherapy (docetaxel) is the first treatment shown to increase overall survival in patients with hormone-resistant prostate cancer, and is today's standard treatment of Norwegian patients (guidelines from the Norwegian Urological Cancer Group). Secondary hormone treatment and administration of bisphosphonates are other established alternatives for palliation of symptoms in patients with hormone-resistant prostate cancer. The survival of future patients with such cancer is expected to improve if multidisciplinary health care teams with knowledge of prostate cancer tumour biology administer new treatments.

High prostate cancer mortality in Norway: Influence of Cancer Registry information?

Norway has among the highest prostate cancer mortality rates in the world. The aim of the present project was to assess whether this can be explained by the unique routine procedure of information transfer from the Cancer Registry of Norway (CR) to the Norwegian Cause of Death Registry (COD Registry). Norwegian prostate cancer patients deceased during 1996 were identified (n=2012). The information basis of the official mortality statistics was reviewed by two physicians, who independently identified the underlying cause of death, primarily prostate cancer or not, supplemented by consensus of two other physicians. The coding was done in two steps; first without, then with CR information. Project physicians identified 1063 deaths from prostate cancer as compared to the official number of 1161, with discrepancy as to prostate cancer death in 126 deceased. Information from the CR increased the project's age-adjusted (world standard population) prostate cancer mortality rate by less than 1% (from 22.7 to 22.9 per 100,000). In conclusion, the high rates of prostate cancer mortality in Norway could not be explained by information transfer from the CR to the COD Registry.

NY-ESO-1 protein expression and humoral immune responses in prostate cancer

BACKGROUND

Due to restricted expression in normal tissues cancer/testis (C/T) antigens represent candidate molecules for immunotherapy of cancer. NY-ESO-1 is a well-studied C/T antigen with unknown expression and immunogenicity in prostate cancer (PC) patients.

METHODS

NY-ESO-1 expression was determined by immunohistochemistry and humoral immune responses against NY-ESO-1 assessed by enzyme-linked immuno-sorbent assay (ELISA) and Western blotting. Protein expression and serological responses were correlated with clinical findings and survival.

RESULTS

NY-ESO-1 expression was found in biopsies from 2 of 66 localized PC and 7/48 hormone refractory prostate cancer (HRPC) patients, respectively. Anti-NY-ESO-1 antibodies were detected in sera from 1 of 112 localized PC and 18 of 95 HRPC patients. Two of four HRPC patients with NY-ESO-1 positive biopsies had mounted a serological response. Positive anti-NY-ESO-1 titers were correlated with poor survival in HRPC patients.

CONCLUSIONS

NY-ESO-1 is expressed in a subset of HRPC patients and, together with other C/T antigens, may serve as a target antigen for development of immunotherapy of PC. Spontaneous serological responses against NY-ESO-1 may be associated with poor survival.

Expression of the epidermal growth factor receptor family in prostate carcinoma before and during androgen-independence

Novel palliative strategies for patients with androgen-independent prostate cancer (AIPC) include targeting the epidermal growth factor receptor (EGFR) family. The aim of the present study was to investigate intrapatient changes of EGFRs during the development of AIPC. In total, 106 symptomatic AIPC patients were identified in whom prostatic biopsies (adenocarcinoma) were available both before the start of androgen deprivation (PRTR biopsy) and after the development of AIPC (AIPC biopsy). All four known subgroups of the EGFR family were determined by immunohistochemistry (IHC): c-erbB-1 (EGFR), c-erbB-2 (HER2/neu), c-erbB-3 (HER3) and c-erbB-4 (HER4). Moderate to strong membrane-specific staining was recorded semiquantitatively (<10% vs ⩾10%=IHC stained tumour cells: ‘negative’ vs ‘positive’ staining). The medical records were reviewed for clinical variables. During the development of AIPC, intrapatient changes occurred in two opposite directions for each of the four EGFRs: negativity changed to positivity, and vice versa, statistically significant only for the increase of c-erbB-1 expression (P=0.001). The c-erbB-2 expression in the AIPC biopsy was associated with a significantly shorter survival from the time of the AIPC biopsy (P=0.029). Our results support ongoing therapeutic attempts of EGFR inhibition in subgroups of patients with prostate cancer. Further research is needed to understand the function of EGFRs in this malignancy.

Androgen-independent prostate cancer--the clinical problem of a growing pelvic tumour

This retrospective study describes three clinically different groups of patients with symptomatic androgen-independent prostate cancer (AIPC) referred to palliative radiotherapy (RT): those with a symptomatic pelvic tumour and pelvis-confined disease (M0 P-RT: 35 patients), those with a symptomatic pelvic tumour and distant metastases (M + P-RT: 97 patients) and those with painful bone metastases (BM-RT: 193 patients). The study emphasises the need of a combined surgical and radiotherapeutic palliation in AIPC patients with symptomatic pelvic tumours. Median overall survival from time of palliative RT was 19, 9 and 8 months for M0 P-RT, M + P-RT and BM-RT patients, respectively (p < 0.001). The significantly prolonged natural course of P-RT patients without distant metastases has to be accounted for in clinical trials of AIPC patients in whom survival represents an endpoint. Furthermore, the optimal palliation regimens for P-RT patients are still to be defined.

[Prostate-specific antigen in the follow-up of conservatively treated prostatic cancer]

The determination of serum prostate specific antigen (PSA) has made the diagnosis of prostate cancer easier. PSA is also used extensively in the follow-up of patients, both treated and untreated. On the basis of material from 308 patients who were mainly managed conservatively, we discuss the usefulness of this practice. It is important to monitor PSA after radical treatment because an increase may indicate local recurrence. In some patients this may lead to further treatment with cure as the aim. For patients under observation only, or those being treated by endocrine intervention, the value of regular PSA measurements is less certain. Where such patients were followed up for at least three years, we found considerable overlaping of PSA values among patients with different outlooks. Within the present therapeutic possibilities it may be better to base their management on clinical signs rather than on PSA. Regular measurements of PSA lead to focusing on this variable, causing unnecessary distress to patients months, or even years, before clinical progression of the disease.