Expanded 99mTc-methylene diphosphonate (MDP) bone scan.

Patients with prostatic cancer frequently require evaluation of bony metastases as well as renal function. 99mTc-methylene diphosphonate, a commonly used bone-imaging agent, is about 60 per cent localized in the bony skeleton and about 40 per cent excreted by the kidneys. Immediate imaging after intravenous injection of the isotope may yield high-quality radionuclide nephrourograms, which provide excellent visual and graphic displays of renal anatomy and excretory function. Our preliminary studies suggest that the immediate 99mTc-methylene diphosphonate scan may usefully expand the value of a routine bone scan to screen for ureteral obstruction. Patients with underlying malignancy who require simultaneous evaluation and follow-up of bony metastases and renal function might be conveniently served by the dual functions of the expanded bone scan to include immediate imaging of the kidneys.

Lysis of osteoblastic lesions in prostatic cancer: a sign of progression.

Osteoblastic metastases from prostatic cancer often increase in density after successful endocrine treatment. Regrowth of malignancy, at the time of relapse, may cause osteolytic changes in previously stable sclerotic lesions. Four illustrative case reports are presented. Fading of sclerotic lesions on radiographs, accompanied by bone destruction, signifies disease progression.

The flare phenomenon on radionuclide bone scan in metastatic prostate cancer.

The radionuclide bone scan 3 months after the initiation of treatment for advanced cancer of the prostate occasionally shows apparent progression of individual lesions despite clinical improvement. To determine the incidence and clinical significance of this so-called flare phenomenon, serial bone scans were reviewed in 33 patients with carcinoma of the prostate and bony metastases, who were receiving endocrine treatment for the first time. A flare reaction was seen in two (6%) of 33 bone scans obtained 3 months after initiation of treatment. A flare reaction on bone scan is an unusual phenomenon in prostatic cancer; in general, serial scans accurately depict the activity of bony metastases in these patients.

Immunohistochemical identification of prostatic acid phosphatase and prostate specific antigen in female periurethral glands.

Periurethral glands were found in 7 of 10 female urethras harvested at autopsy. In all 7 cases, immunoperoxidase staining showed the presence of prostatic acid phosphatase in glandular acini. By similar techniques, prostate specific antigen was demonstrated in acini of 4 of 7 urethras with periurethral glands. The findings support a female homologue of the male prostate.

Detection of ureteral obstruction on radionuclide bone scans.

The kidneys are nearly always visible on a routine radionuclide bone scan. To assess the reliability of the bone scan in detecting ureteral obstruction, 220 bone scans and excretory urograms were compared in 53 patients followed serially for prostatic cancer. There were 15 kidneys obstructed on excretory urograms. Only nine were diagnosed as obstructed on the bone scans. Seven of the nine cases of unilaterally obstructed kidneys were detected, whereas only two of the six kidneys in three patients with bilateral obstruction were correctly diagnosed. The results indicate that unilateral obstruction is more likely to be detected, whereas bilateral obstruction is more likely to be missed, on bone scans. Therefore, the routine radionuclide bone scan is an unreliable test for ureteral obstruction.

Successful treatment of interstitial cystitis with sodium pentosanpolysulfate.

The surface of the bladder is lined by a layer of sulfonated glycosaminoglycans, of which the nonspecific anti-adherence effect is reproduced by synthetic sulfonated glycosaminoglycans. This mucous layer appears to be the most important line of defense between the transitional cells and all harmful substances in the urine. Many disease states may be associated with a deficiency in the anti-adherence activity of the glycosaminoglycan layer and may benefit from treatment with synthetic glycosaminoglycans. One such disease is interstitial cystitis. We administered oral sodium pentosanpolysulfate (Elmiron), a synthetic analogue of a sulfonated glycosaminoglycan, to 24 patients with interstitial cystitis. Within 4 to 8 weeks of initiation of treatment 20 patients experienced a decrease of at least 80 per cent in pain, urgency and nocturia, and 2 experienced a 50 to 80 per cent decrease in these symptoms. The 22 patients who responded continue to experience progressive improvement with time.

Endocrine treatment of prostatic cancer.

Data are drawn from the pertinent literature supporting diethylstilbestrol for initial endocrine treatment of advanced prostatic cancer. When diethylstilbestrol is given in a dosage of 2 mg daily, the risk of cardiovascular complications is low. Bilateral orchiectomy is reserved for high-risk patients or those intolerant of estrogen. To prevent possible complications of uncontrolled tumor growth and perhaps to increase survival time, endocrine treatment of advanced prostatic cancer should be started early.

Traumatic dislocation of the testes.

A case of bilateral inguinal dislocation of the testes in a motorcycle accident is reported and its pathogenesis is described. The injury probably results from the gasoline tank striking the perineum and the scrotum in the midline, causing upward and outward displacement of the testes and forcible herniation of the gonads through the coverings of the spermatic cord. If efforts at closed reduction are unsuccessful, management requires surgical exploration and orchiopexy. Results of semen analysis suggest that the prognosis for recovery of fertility potential after this repair of bilateral dislocation of the testes is good.

Whither pelvic lymphadenectomy in prostatic cancer?

In the last decade pelvic lymphadenectomy has gained in popularity as a staging maneuver designed to improve the selection of patients with localized prostatic cancer for curative treatment, by uncovering lymph node metastases. The presence of tumor in the regional nodes portends substantial risk for the later appearance of distant metastases. With rare exceptions, lymphadenectomy is widely regarded as a staging procedure without therapeutic benefits. Unfortunately, the operation as routinely performed carries a significant complication rate. The survival results of total prostatectomy for well-selected nodules of prostatic cancer are excellent without preliminary lymphadenectomy. The morbidity of lymphadenectomy is compounded by superimposed external irradiation. Because of the low complication rate from external radiation alone, it is suggested that patients selected for pelvic radiation be spared the discomfort of lymphadenectomy. Clinical trials of adjuvant chemotherapy in patients with minimal nodal disease may answer the question of whether pelvic lymphadenectomy should ever be performed. It is predicted that noninvasive imaging will improve to the point that staging lymphadenectomy may be relegated to the surgical archives.

The value of nuclear bone imaging in advanced prostatic cancer.

The nuclear bone scan is a highly sensitive means of detecting skeletal metastasis in patients with prostatic cancer. Serial bone imaging provides an accurate method to follow the response of osseous metastases to treatment and to detect relapsing disease in the skeleton. In selected instances the nuclear bone scan can provide information about vertebral metastases that can be important for planning palliative treatment of pain.

Antibacterial activity of bladder surface mucin duplicated in the rabbit bladder by exogenous glycosaminoglycan (sodium pentosanpolysulfate).

Previous data from our laboratory suggest that the transitional epithelium of the urinary bladder secretes and binds to its surface a glycosaminoglycan. The presence of this substance at the bladder surface markedly reduces the ability of microorganisms to adhere to the mucosa. Furthermore, this glycosaminoglycan can be removed (with acid) and replaced by intravesical instillation of a synthetic sulfonated glycosaminoglycan (heparin), whose presence is as effective as that of the natural glycosaminoglycan in reducing adherence. We conducted the current study with a different sulfonated glycosaminoglycan to determine whether the antiadherence activity is generalized to heparin congeners and whether the antiadherence effect of heparin is independent of its known anticoagulant activity. In this study we examined the sulfonated glycosaminoglycan, sodium pentosanpolysulfate, which lacks significant anticoagulant activity, and found it to have a mechanism of antiadherence analogous to that of heparin and almost equally as active on a weight basis.

Thrombocytopenia during diethylstilbestrol diphosphate (stilphostrol) infusion for carcinoma of the prostate.

Transient thrombocytopenia was noted to occur in ten of 13 patients with advanced carcinoma of the prostate undergoing intravenous diethylstilbestrol diphosphate therapy. This was not associated with abnormalities of the initial platelet count or other parameters of the hemogram. There was no evidence of disseminated intravascular coagulation in these patients. No serious bleeding episodes occurred secondary to the thrombocytopenia. Following diethylstilbestrol diphosphate infusion, platelet counts generally returned to pretreatment levels. While the mechanism of action of the thrombocytopenia is unclear, we hypothesize a transient bone marrow toxicity as the cause of this phenomenon.

The role of radiography, computed tomography and bone scanning in prostatic cancer.

This report reviews the roles of conventional radiography, computerized axial tomography, and nuclear bone scanning in the diagnosis, staging, follow-up, and management of prostatic cancer. Computed tomography (CT) offers great promise for the better definition of the extent of the primary tumor of prostatic cancer. It contributes positively to the planning of radiation therapy portals in the treatment of localized disease. By means of bipedal lymphangiography and CT scanning, pelvic and periaortic lymphadenopathy may be detected more often than was previously possible without staging pelvic lymphadenectomy, which can be reserved for the discovery of microscopic disease. Soft-tissue metastases that are located deep within the body cavities can now be measured accurately by CT scanning, as can their response to therapy. Skeletal metastases, the most common variety in prostatic cancer, can be detected with a high degree of sensitivity by nuclear bone imaging. Serial bone scans are remarkably useful in following the response of osseous deposits to treatment, as well as in detecting relapsing disease. The management of malignant obstruction of the ureters has been greatly facilitated by the application of angiographic techniques to percutaneous nephrostomy performed under fluoroscopic control.