Bone metastases from prostate cancer: 18F-fluoride PET/CT in a patient with discordant bone scintigraphy and 11C-choline PET/CT

Whole-body diffusion-weighted magnetic resonance imaging (WB-DW-MRI) vs choline-positron emission tomography-computed tomography (choline-PET/CT) for selecting treatments in recurrent prostate cancer

OBJECTIVE

To determine the effectiveness of whole-body diffusion-weighted magnetic resonance imaging (WB-DW-MRI) in detecting metastases by comparing the results with those from choline-positron emission tomography-computed tomography (choline-PET/CT) in patients with biochemical relapse after primary treatment, and no metastases in bone scintigraphy, CT and/or pelvic MRI, or metastatic/oligometastatic prostate cancer (PCa). Patients with this disease profile who could benefit from treatment with stereotactic body radiation therapy (SBRT) were selected and their responses to these techniques were rated.

MATERIALS AND METHODS

This was a prospective, controlled, unicentric study, involving 46 consecutive patients from our centre who presented biochemical relapse after adjuvant, salvage or radical treatment with external beam radiotherapy, or brachytherapy. After initial tests (bone scintigraphy, CT, pelvic MRI), 35 patients with oligometastases or without them were selected. 11 patients with multiple metastases were excluded from the study. WB-DW-MRI and choline-PET/CT was then performed on each patient within 1 week. The results were interpreted by specialists in nuclear medicine and MRI. If they were candidates for treatment with ablative SBRT (SABR), they were then evaluated every three months with both tests.

RESULTS

Choline-PET/CT detected lesions in 16 patients that were not observable using WB-DW-MRI. The results were consistent in seven patients and in three cases, a lesion was observed using WB-DW-MRI that was not detected with choline-PET/CT. The Kappa value obtained was 0.133 (p = 0.089); the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of WB-DW-MRI were estimated at 44.93, 64.29, 86.11, and 19.15%, respectively. For choline-PET/CT patients, the sensitivity, specificity, PPV, and NPV were 97.10, 58.33, 93.06, and 77.78%, respectively.

CONCLUSIONS

Choline-PET/CT has a high global sensitivity while WB-DW-MRI has a high specificity, and so they are complementary techniques. Future studies with more enrolled patients and a longer follow-up period will be required to confirm these data. The initial data show that the best technique for evaluating response after SBRT is choline-PET/CT. Trial registration number NCT02858128.

When to perform positron emission tomography/computed tomography or radionuclide bone scan in patients with recently diagnosed prostate cancer

Skeletal metastases are very common in prostate cancer and represent the main metastatic site in about 80% of prostate cancer patients, with a significant impact in patients’ prognosis. Early detection of bone metastases is critical in the management of patients with recently diagnosed high-risk prostate cancer: radical treatment is recommended in case of localized disease; systemic therapy should be preferred in patients with distant secondary disease. Bone scintigraphy using radiolabeled bisphosphonates is of great importance in the management of these patients; however, its main drawback is its low overall accuracy, due to the nonspecific uptake in sites of increased bone turnover. Positron-emitting radiopharmaceuticals, such as fluorine-18-fluorodeoxyglucose, choline-derived drugs (fluorine-18-fluorocholine and carbon-11-choline) and sodium fluorine-18-fluoride, are increasingly used in clinical practice to detect metastatic spread, and particularly bone involvement, in patients with prostate cancer, to reinforce or substitute information provided by bone scan. Each radiopharmaceutical has a specific mechanism of uptake; therefore, diagnostic performances may differ from one radiopharmaceutical to another on the same lesions, as demonstrated in the literature, with variable sensitivity, specificity, and overall accuracy values in the same patients. Whether bone scintigraphy can be substituted by these new methods is a matter of debate. However, greater radiobiological burden, higher costs, and the necessity of an in-site cyclotron limit the use of these positron emission tomography methods as first-line investigations in patients with prostate cancer: bone scintigraphy remains the mainstay for the detection of bone metastases in current clinical practice.