Imaging prostate cancer: current and future applications.

Various treatment options are available for adenocarcinoma of the prostate--the most common malignant neoplasm among men in the United States. To select an optimum management strategy, we must be able to identify an organ-confined disease (in which local therapy such as surgery or radiation may be beneficial) vs prostate cancer beyond the confines of the gland (for which other treatment approaches may be more appropriate). At present, no standard imaging modality can by itself reliably diagnose and/or stage adenocarcinoma of the prostate. Standard transrectal ultrasound, magnetic resonance imaging (MRI), computed tomography, bone scans, and plain x-ray are not sufficiently reliable when used alone. Fortunately, advances in imaging technology have led to the development of several promising modalities. These modalities include color and power Doppler ultrasonography, ultrasound contrast agents, intermittent and harmonic ultrasound imaging, MR contrast imaging, MRI with fat suppression, MRI spectroscopy, three-dimensional MRI spectroscopy, elastography, and radioimmunoscintigraphy. These newer imaging techniques appear to improve the yield of prostate cancer detection and staging, but are limited in availability and thus require further validation. This article reviews the status of current imaging modalities for prostate cancer and identifies emerging imaging technologies that may improve the diagnosis and staging of this disease.

Surveillance of upper urinary tract transitional cell carcinoma: the role of ureteroscopy, retrograde pyelography, cytology and urinalysis.

PURPOSE: A select group of patients with upper tract transitional cell carcinoma are treated with ureteroscopic resection. We determine the validity and accuracy of urinalysis, bladder cytology, upper tract biopsy/cytology and retrograde pyelography for the detection of recurrent upper tract transitional cell carcinoma compared to endoscopic findings. MATERIALS AND METHODS: Patients with ureteroscopically treated upper tract transitional cell carcinoma were followed with surveillance every 3 to 6 months. Surveillance included urinalysis with dipstick and microscopic examination, bladder cytology, retrograde pyelography read by a urologist and radiologist, and ureteropyeloscopy with cytology and biopsy of suspicious areas. Not all results were available for all surveillance procedures. Measures of sensitivity and specificity for the aforementioned surveillance procedures were determined relative to endoscopic findings that were defined as the standard. Confidence intervals were also estimated. Initially, a generalized estimation equation approach was used to take into account the clustering of repeated testing within patients. The accuracy of each procedure was also calculated. RESULTS: There were 23 patients with previously resected low grade upper tract transitional cell carcinoma who underwent a total of 88 surveillances in 30 months. A total of 56 of 88 (64%) recurrences were detected ureteroscopically, including 11 (12%) associated bladder recurrences. In patients who did not have bladder recurrences urinalysis had a sensitivity of 37.5% but specificity was 85%, while bladder cytology had a sensitivity of 50% and specificity was 100%, and retrograde pyelography read in the endoscopy room revealed a sensitivity of 71.7% and specificity of 84.7%. Ureteroscopic biopsy/cytology had a sensitivity and specificity of 93.4% and 65.2%, respectively. CONCLUSIONS: Our findings indicate that compared to ureteroscopy, urinalysis, bladder cytology, retrograde pyelography and ureteroscopic cytology/biopsy are less valid and accurate in detecting upper tract transitional cell carcinoma recurrences. Based on our data we recommend ureteroscopic evaluation as an essential procedure for the surveillance of patients treated endoscopically for upper tract transitional cell carcinoma.

The multidisciplinary clinic approach to prostate cancer counseling and treatment.

The optimum management for an individual patient with prostate cancer is not well defined. Patients with localized disease may be offered options ranging from observation, hormonal therapy, cryotherapy, radiation therapy, or surgery. Each option may have unique aspects to consider when counseling a patient often leading to multiple physician visits over an extended period of time. Since 1996, the Kimmel Cancer Center of Thomas Jefferson University has offered newly diagnosed urologic cancer patients the opportunity to be evaluated in a multidisciplinary clinic. Here, multiple physician consultative visits, including pathologic and radiologic evaluation and protocol evaluation, are provided during the session. Herein we report on our experience with this multidisciplinary approach for patients with prostate cancer.

Deciding on radical prostatectomy: the physician's perspective.

Patients and physicians often face a difficult process in determining which treatment option to pursue for localized prostate cancer. Observation, hormonal therapy, cryotherapy, various forms of radiation therapy, and surgery all may be offered as options depending on many factors, such as age, the patient's overall health, clinical stage, and opinions of both the physician and the patient. In the information age of computers and the new openness about prostate cancer, a wealth of data can be obtained by the patient, the patient's family, and the physician on these various modalities. This article focuses on the role of surgery as a primary treatment modality for clinically localized prostate cancer from the urologist's prospective. The indications, the merits of retropubic versus perineal, and the reported morbidity and mortality associated with radical prostatectomy are discussed. The procedure is also compared with conservative management and radiation as treatment modalities for localized prostate cancer.

Undetectable prostate-specific antigen response with bicalutamide withdrawal phenomenon.

Several reports have described the antiandrogen withdrawal syndrome with various nonsteroidal antiandrogen agents. To our knowledge, there have been no reports describing a durable undetectable prostate-specific antigen (PSA) response with discontinuation of the antiandrogen agent bicalutamide (Casodex, Zeneca, Wilmington, DE, U.S.A.). We report a case in which a decline of serum PSA to undetectable levels was achieved with bicalutamide discontinuation.

Low serum insulin-like growth factor 1 (IGF-1): a significant association with prostate cancer.

PURPOSE: Insulin-like growth factor 1 (IGF-1) is an important mitogenic and antiapoptotic peptide that affects the proliferation of normal and malignant cells. Contradictory reports on the association between serum IGF-1 level and prostate cancer have been highlighted in the recent literature. The purpose of this study was to investigate the relation between serum levels of IGF-1 and prostate cancer. MATERIALS AND METHODS: We analyzed a population of 57 patients who underwent radical prostatectomy (RP) for adenocarcinoma. Serum samples were collected before RP (T0), 6 months after RP (T6), and from 39 age-matched controls. IGF-1 levels were determined by the active IGF-1 Elisa kit (Diagnostic Systems Laboratories, Inc.). Parallel samples were evaluated for prostate-specific antigen (PSA) levels. Data between groups were analyzed using Welch's t-test and levels before RP and after 6 months were compared by paired t-test. RESULTS: The normal mean serum IGF-1 for case patients at T0 (124.6+/-58.2 ng/mL) was significantly lower than the control subjects (157.5+/-70.8 ng/mL; p = .0192). The normal mean serum IGF-1 for case patients at T0 (124.91+/-58.6 ng/mL) also was significantly lower when it was compared with the T6 group (148.49+/-57.2 ng/mL; p = .0056). No association was found between IGF-1 and PSA blood levels, or IGF-1 and patient weight (p = 0.2434). An inverse relation between IGF-1 levels and age in the normal controls (p = .0041) was observed. CONCLUSION: Findings of this study indicate a significant association between low serum levels of IGF-1 and prostate cancer.

Retrieval capabilities of different stone basket designs in vitro.

BACKGROUND AND OBJECTIVE: Several designs of endoscopic stone retrieval baskets are available. Each instrument has special characteristics which can be employed in different locations with different techniques and various effects. In this study, we compared the retrieval capability of five basket designs in two in vitro models. MATERIALS AND METHODS: The five baskets were a flat wire (Segura), Parachute, N-0-tip, and two helical designs. The ability of the baskets to retrieve beads of 4, 6, and 8 mm was compared in two models. Each size was used individually, and four beads of the 4-mm size were also studied. In the first model, single and multiple beads were placed in a cylindrical plastic tube to mimic removal of the stone from the ureter. In single-bead retrieval trials, the basket was opened beyond the bead and withdrawn, whereas with multiple beads, the basket was opened beyond, withdrawn, and closed. Bead engagement and removal was considered a successful retrieval. Three repetitions were performed for each basket and each bead size. In the second model, similar beads were placed in a round-bottom test tube to simulate a stone within a calix. The basket was opened at the base of the tube and closed. The number of beads removed was noted for three repetitions for each basket. RESULTS: All baskets were able to retrieve the 4-, 6-, and 8-mm beads from the cylinder, with the exception of the four-wire helical basket, which failed in two of the three retrieval attempts for the 4- and 6-mm beads, and the double-helical basket, which failed in two of the three retrieval attempts for the 4-mm bead. When four beads 4 mm in size were used, the Parachute and double-helical baskets retrieved all of them within two trials and the N-0-tip and four-wire helical baskets within three trials. The Segura basket failed all trials. In the test tube model, all baskets failed to remove any beads with the exception of the N-0-tip, which was successful in removing a single bead with each positioning. CONCLUSIONS: In these in vitro models, it was apparent that the design of the basket affects its ability to retrieve calculi in different situations.