https://www.europeanurology.com/article/S0302-2838(07)01145-1/pdf/eau-guidelines-on-prostate-cancer

EAU guidelines on prostate cancer

The introduction of an effective blood test, prostate specific antigen (PSA), has made it possible to diagnose more and more men in an earlier stage where they can be offered potentially curative treatments. The other side of the coin is that if effective diagnostic procedures are used unselectively in elderly men with a short life expectancy, a problem with over diagnosis and over treatment might occur. Thus the same stage of prostate cancer may need different treatment strategies, pending on the patient’s life expectancy. This, and many other issues regarding the disease, is the subject of the EAU guidelines on prostate cancer. G UI DE LI N ES O N P RO ST AT E CA N CE R 10

/pdf/guidelines-on-prostate-cancer-xdnunn4th8.pdf

Guidelines on Prostate Cancer

Predicting Radionuclide Bone Scan Findings in Patients with Newly Diagnosed, Untreated Prostate Cancer: Prostate Specific Antigen is Superior to All Other Clinical Parameters

Objective. —To assess the need for obtaining radionuclide bone scans in the staging evaluation of patients with newly diagnosed, untreated prostate cancer. This determination was made on the basis of presenting prostate-specific antigen (PSA) levels. Design. —Retrospective review. Participants. —The medical records of 2064 consecutive patients with prostate cancer who were evaluated at the Mayo Clinic in Rochester, Minn, from January 1989 through December 1990 were reviewed. Eight hundred fifty-two patients with newly diagnosed, untreated disease and a serum PSA concentration less than 20.0 μg/L at presentation comprised the study population. Main Outcome Measure. —The rate of false-negative results associated with using the serum PSA concentration to predict bone scan findings. Results. —Five hundred sixty-one patients had a serum PSA concentration of 10.0 μg/L or less; only three had an abnormal bone scan result, and one had an indeterminate scan result. Of the 467 men whose PSA value was 8.0 μg/L or less (two times the upper limit of the reference range), none had bone scan results that were either abnormal or indeterminate. The rate of false-negative results for an abnormal bone scan result was 0% with a serum PSA value of 8.0 μg/L or less and 0.5% with a cutoff level of 10.0 μg/L. The 95% upper confidence limit for the rate of false-negative results for all PSA cutoff levels less than 20.0 μg/L was less than 2%. Conclusions. —For patients with newly diagnosed, untreated prostate cancer, a serum PSA concentration of 10.0 μg/L or less, and no skeletal symptoms, a staging radionuclide bone scan does not appear to be necessary. This clinical situation applies to 39% of all patients presenting with newly diagnosed prostate cancer. Since more than 130 000 new cases are diagnosed each year, approximately 50 000 patients are affected annually. If the $600 staging bone scan were eliminated for these patients, a significant economic savings to the health care system in this country would be effected. ( JAMA . 1993;269:57-60)

The Use of Prostate-Specific Antigen in Staging Patients With Newly Diagnosed Prostate Cancer

Natural History and Staging of Prostate Cancer

Summary— Bone scanning with 99mTc-Sn-HEDP, radiographic skeletal survey and determination of plasma acid and alkaline phosphatase values were carried out in a consecutive series of 90 untreated patients with carcinoma of the prostate.



99mTc-Sn-HEDP provided satisfactory bone imaging and was convenient in use.



The addition of bone scanning to radiographic survey increases the detection rate of skeletal metatases by 16%.



Radiography increases the accuracy of bone scanning by identifying false positive scans due to benign disease and false negative scans when there are diffuse symmetrical bony metastases.



The plasma phosphatases alone are less accurate staging tests. The acid phosphatase data support the validity of scan positive—X-ray negative findings. Bone scan abnormalities due to secondary deposits usually precede elevation of plasma alkaline phosphatase.

Bone scanning and plasma phosphatases in carcinoma of the prostate.

Summary— Serial bone scans and radiographic surveys were performed in 167 patients with histologically proven carcinoma of the prostate: 435 scans and surveys were performed.



Nineteen of 99 patients with negative findings on diagnosis have become positive on follow-up. Forty-nine patients had positive findings on presentation; 8 have regressed on follow-up and 26 have progressed; 15 have remained unchanged.



This is a sensitive method of follow-up in patients with carcinoma of prostate. Changes occurred in bone scans and skeletal surveys before any alteration in serum acid or alkaline phosphatases, symptoms of metastases or change in prostatic size in the majority of cases.



The documentation of progression from MO to M1 disease presents no problems. However, problems in quantitation may arise in patients presenting with M1 disease.

Serial Bone Scanning: The Assessment of Treatment Response in Carcinoma of the Prostate

Summary— A simple method for demonstrating prostatic lymphatic drainage by transrectal injection of 99mTc labelled antimony sulphide colloid into the prostatic capsule has been developed. This technique may be readily applied in clinical practice with obvious potential in the assessment and follow‐up of patients with carcinoma of the prostate. Copyright

Human Prostatic Lymphoscintigraphy. A Preliminary Report

Summary— Further improvements have been made in the technique of human prostatic lymphoscintigraphy, allowing better anatomical localisation of the areas of uptake of activity. A single median injection into the capsule of Tc labelled antimony sulphide colloid has been found to give as good imaging as 2 injections on either side of the midline. By placing markers on the umbilicus, pubic symphysis and both anterior superior iliac spines, a “pelvic grid” can be superimposed on the antero‐posterior view. Further help with accurate localisation may be attained by taking 3 views; antero‐posterior, postero‐anterior and lateral. In 9 instances, prostatic injection was performed without any sedation or anaesthesia. The resulting scintigrams were indistinguishable in quality from those of anaesthetised patients.

Improved Techniques in Radionuclide Imaging of Prostatic Lymph Nodes

Fifty-five patients with diffuse pain due to bone metastases from prostate carcinoma were treated by pituitary ablation (53 with intrasellar Yttrium 90 and 2 with intrapituitary alcohol instillation). The provisional criteria of the British Prostate Group were used to assess results. Post-operatively, 44 patients (80%) were significantly free of pain and 12 of them were completely pain-free. In only 11 cases (20%) was there no relief of pain. Of the 39 patients who required narcotics before ablation, only 12 required them post-operatively. Pituitary ablation with Yttrium 90 has an important place in the relief of pain in advanced carcinoma of the prostate, although survival is not increased.

E. P. N. O'donoghue

Papers

Bone scanning and plasma phosphatases in carcinoma of the prostate.

Serial Bone Scanning: The Assessment of Treatment Response in Carcinoma of the Prostate

Human Prostatic Lymphoscintigraphy. A Preliminary Report

Improved Techniques in Radionuclide Imaging of Prostatic Lymph Nodes

Pituitary ablation in the relief of pain in advanced prostatic carcinoma.