[18F]fluoromethylcholine (FCH) positron emission tomography/computed tomography (PET/CT) for lymph node staging of prostate cancer: a prospective study of 210 patients.

UNLABELLED: Study Type--Diagnostic (exploratory cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? Staging of patients with prostate cancer is the cornerstone of treatment. However, after curative intended therapy a high portion of patients relapse with local and/or distant recurrence. Therefore, one may question whether surgical lymph node dissection (LND) is sufficiently reliable for staging of these patients. Several imaging methods for primary LN staging of patients with prostate cancer have been tested. Acceptable detection rates have not been achieved by CT or MRI or for that matter with PET/CT using the most common tracer fluoromethylcholine (FCH). Other more recent metabolic tracers like acetate and choline seem to be more sensitive for assessment of LNs in both primary staging and re-staging. However, previous studies were small. Therefore, we assessed the value of [(18) F]FCH PET/CT for primary LN staging in a prospective study of a larger sample and with a 'blinded' review. After a study period of 3 years and >200 included patients, we concluded that [(18) F]FCH PET/CT did not reach an optimal detection rate compared with LND, and, therefore, it cannot replace this procedure. However, we did detect several bone metastases with [(18) F]FCH PET/CT that the normal bone scans had missed, and this might be worth pursuing. OBJECTIVES: • To assess the value of [(18) F]fluoromethylcholine (FCH) positron emission tomography/computed tomography (PET/CT) for lymph node (LN) staging of prostate cancer. • To evaluate if FCH PET/CT can replace LN dissection (LND) for LN staging of prostate cancer, as about one-third of patients with prostate cancer who receive intended curative therapy will have recurrence, one reason being undetected LN involvement. PATIENTS AND METHODS: • From January 2008 to December 2010, 210 intermediate- or high-risk patients had a FCH PET/CT scan before regional LND. • After dissection, the result of histological examination of the LNs (gold standard) was compared with the result of FCH PET/CT obtained by 'blinded review'. • Sensitivity, specificity, positive (PPV), and negative predictive values (NPV) of FCH PET/CT were measured for detection of LNe metastases. RESULTS: • Of the 210 patients, 76 (36.2%) were in the intermediate-risk group and 134 (63.8%) were in the high-risk group. A medium (range) of 5 (1-28) LNs were removed per patient. • Histological examination of removed LNs showed metastases in 41 patients. Sensitivity, specificity, PPV, and NPV of FCH PET/CT for patient-based LN staging were 73.2%, 87.6%, 58.8% and 93.1%, respectively. • Corresponding values for LN-based analyses were 56.2%, 94.0%, 40.2%, and 96.8%, respectively. • The mean diameter of the true positive LN metastases was significantly larger than that of the false negative LNs (10.3 vs 4.6 mm; P < 0.001). • In addition, FCH PET/CT detected a high focal bone uptake, consistent with bone metastases, in 18 patients, 12 of which had histologically benign LNs. CONCLUSIONS: • Due to a relatively low sensitivity and a correspondingly rather low PPV, FCH PET/CT is not ideal for primary LN staging in patients with prostate cancer. • However, FCH PET/CT does convey important additional information otherwise not recognised, especially for bone metastases.

Effect of endocrine treatment on voiding and prostate size in men with prostate cancer: a long-term prospective study.

OBJECTIVE: The aim of this study was to assess and quantify changes in voiding parameters and prostate size in men with prostate cancer from before the start of endocrine treatment and during long-term follow-up. MATERIAL AND METHODS: Seventy-seven patients were recruited from three clinics and followed prospectively until death, clinical deterioration making the patient unfit for participation, or the end of the study. Median age was 74 (range 54-85) years, and the median follow-up was 18 (3-90) months. Parameters and endpoints were total score on the Danish Prostatic Symptom Score (DAN-PSS-1) questionnaire, maximum flow rate, postvoid residual volume, frequency and voided volume, and prostate volume on transrectal ultrasonography. RESULTS: All parameters improved significantly in the range of median 13-50% within the first 12 months. The greater part of the effect occurred during the first month, and thereafter the improvement rate slowed down. Intervention for local progression was estimated on Kaplan-Meier analysis to be about 20% after 4 years. 73% had a defined prostate-specific antigen nadir after a median of 6 (1-60) months with scheduled assessments up to 72 months after the nadir. All parameters were improved before the nadir and the improvement remained during biochemical progression except for the very latest visits where few patients contributed to the analyses. CONCLUSIONS: Androgen deprivation therapy improved lower urinary tract symptoms, objective voiding parameters and prostate volume in patients with prostate cancer who were not candidates for curative treatment. The improvement was significant within the first month and clinically relevant. Despite biochemical progression the effect may last for years, and only a minority will need intervention for local progression.

[18F]-fluorocholine positron-emission/computed tomography for lymph node staging of patients with prostate cancer: preliminary results of a prospective study.

OBJECTIVES: To evaluate prospectively [(18)F]-fluorocholine positron-emission/computed tomography (FCH PET/CT) for lymph node staging of prostate cancer before intended curative therapy, and to determine whether imaging 15 or 60 min after radiotracer injection is preferable. PATIENTS AND METHODS: In all, 25 consecutive patients with newly diagnosed prostate cancer (Gleason score >6, and/or a prostate-specific antigen level of >10 ng/mL, and/or T3 cancer) were scanned before lymphadenectomy. Each patient was assessed twice with imaging, at 15 and 60 min after the injection with FCH. Images were compared with the results of histopathological examination of the surgically removed lymph nodes. Maximum standardized uptake values (SUV(max) ) at 15 and 60 min were also compared. RESULTS: Histopathologically, metastases were present in removed lymph nodes from three patients. FCH PET/CT showed a high radiotracer uptake in four patients, the former three and a fourth. The sensitivity, specificity, positive and negative predictive value of FCH PET/CT for patient based lymph node staging of prostate cancer were 100%, 95%, 75% and 100%, respectively; the corresponding 95% confidence intervals were 29.2-100%, 77.2-99.9%, 19.4-99.4% and 83.9-100%, respectively. Values of SUV(max) at early and late imaging were not significantly different. CONCLUSIONS: This small series supports the use of FCH PET/CT as a tool for lymph node staging of patients with prostate cancer. Values of SUV(max) at early and late imaging did not differ. However, larger prospective studies are needed to validate these findings.

Prostate cancer: a review of active surveillance.

The objective of this paper is to review the current recommendations for active surveillance in prostate cancer from the present prospective studies. Worldwide, there are increasing numbers of men with prostate cancer. It is now accepted as standard care that a number of men with favorable-risk disease can be followed with active surveillance. In 1995, the first prospective studies were initiated to assess the feasibility of active surveillance, in which the decision to intervene was determined by prostate-specific antigen and/or histological progression. The strategy was to provide therapy individualized to the biological behavior of the cancer. Clinical trials assessing active surveillance have usually included patients younger than 70 years of age, although the guidelines have changed over time for Gleason score and prostate-specific antigen, eg, doubling time, thereby changing the indication for active treatment. The present review focuses on patient selection, prospective studies reported in the literature, and future directions.

[Metastasis in testis from prostate cancer].

We present a case of an 89-year-old male diagnosed with a prostatic adenocarcinoma. He developed a metastasis to his left testis and was treated with bilateral orchiectomy. Histology showed a ductal adenocarcinoma with positive immunohistochemical markers for PSA and p501. Testicular metastases from prostate cancer are rare and are assumed to be associated with progressed disease and poor prognosis. Ductal adenocarcinomas may be associated with a higher risk of dissemination to the testis.

[Laparoscopy-assisted cryoablation of small kidney tumours]. / Laparoskopisk assisteret kryobehandling af nyretumorer.

INTRODUCTION: During the last 10 years, the number of incidentally found renal tumours has increased from 60 to 75%. Treatment modalities for these small tumours include nefron sparing surgery performed as partial nefrectomy, RFA (radio frequency ablation) or cryoablation. The purpose of this study is to present the first Danish experiences with laparoscopic assisted cryoablation of small kidney tumours. MATERIALS AND METHODS: During a period of 11 months, seven patients were treated with the procedure. All tumours were renal cell carcinomas verified on biopsy. The cryoablation (Oncura) was performed using the SeedNet system. The cryo-ablation was performed using 1.47 mm needles placed in the tumour. Ablation used Argon for freezing and Helium for thawing under high pressure (300 bar). RESULTS: A total of seven patients (median age 77 years (47-83)) were included in the study. The average operating time was 2 hours and 5 minutes. We experienced no complications during surgery and all patients were discharged the day after surgery. All patients were followed with blood samples, x-ray of the thorax and contrast CT of the abdomen. All tumours were found to be well treated, but one demonstrated slight contrast enhancement in the tumour region on control CT. CONCLUSION: Our initial experiences with laparoscopic assisted cryoablation of small kidney tumours show that this treatment modality is safe and effective. However, longer follow-up is needed for this procedure.