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Table of Contents
Year : 2010  |  Volume : 47  |  Issue : 4  |  Page : 385-390

Complimentary role of FDG-PET imaging and skeletal scintigraphy in the evaluation of patients of prostate carcinoma

1 Radiation Medicine Centre, Bhabha Atomic Research Centre, TATA Memorial Hospital, Jerbai Wadia Road, Parel, Mumbai - 400 012, India
2 Department of Surgery, TATA Memorial Hospital, Jerbai Wadia Road, Parel, Mumbai - 400 012, India

Date of Web Publication4-Dec-2010

Correspondence Address:
S Basu
Radiation Medicine Centre, Bhabha Atomic Research Centre, TATA Memorial Hospital, Jerbai Wadia Road, Parel, Mumbai - 400 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.73572

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 » Abstract 

Prostate cancer is one of the most common malignancies of elderly males. Management depends on the accurate estimation of disease both at initial diagnosis and in its subsequent course. In the present study, we evaluated the diagnostic utility of positron emission tomography with 18 F-fluorodeoxyglucose (FDG-PET) in patients having prostate cancer. The findings were compared with the results of bone scan (BS) for the detection of bone metastases. Sixteen patients (age range, 55-83 years) with confirmed diagnosis of prostate cancer were included in the prospective study. Three patients had undergone bilateral orchidectomy, 1 had hormonal therapy, 9 had undergone both, and 3 had no therapy. All the patients underwent wholebody BS and FDG-PET within 1 week. Interpretation of BS and FDG-PET were performed qualitatively. Osseous abnormalities detected by both methods were compared. Involvement of the disease in other sites as seen on FDG-PET was also noted. BS detected 197 osseous lesions, whereas FDG-PET could detect 97 (49%) bone lesions. However, in 3 patients without any prior therapeutic intervention, FDG-PET results were superior or equivalent to that of BS. FDG-PET also detected extensive involvement of the disease in the bone marrow in 4 patients, lymph node metastases at various sites in 8, liver metastases in 2, and lung metastases in 1 patient. FDG-PET could demonstrate less number of osseous metastases in comparison with BSs, but the results have to be interpreted in the background of prior treatment administered and the tumor biology of the lesion. It is evident that FDG-PET could detect the unknown soft tissue involvement of the disease with good sensitivity, which might play an important role in the management of prostate cancer. Overall, in the absence of novel PET tracers, both skeletal scintigraphy and FDG-PET imaging can play a complimentary role in the management of prostate cancer.

Keywords: Bone scan, FDG-PET, prostate carcinoma, scintigraphy

How to cite this article:
Tiwari B P, Jangra S, Nair N, Tongaonkar H B, Basu S. Complimentary role of FDG-PET imaging and skeletal scintigraphy in the evaluation of patients of prostate carcinoma. Indian J Cancer 2010;47:385-90

How to cite this URL:
Tiwari B P, Jangra S, Nair N, Tongaonkar H B, Basu S. Complimentary role of FDG-PET imaging and skeletal scintigraphy in the evaluation of patients of prostate carcinoma. Indian J Cancer [serial online] 2010 [cited 2022 May 17];47:385-90. Available from:

 » Introduction Top

Prostate cancer is one of the most common neoplasms in elderly males and is the second most frequent cause of death by cancer [1] in this group of patients. The standard method for detection of the disease is digital rectal examination. Serum levels of prostate-specific antigen (PSA) and Gleason's scoring have been found useful in the evaluation of prostrate adenocarcinoma. [2],[3] A noninvasive imaging technique to detect recurrent and metastatic prostate cancer is important for effective management of such patients. The imaging methods, such as ultasonography, computed tomography (CT), magnetic resonance imaging, and imaging with 111 In-Protascint, have been used with varying degrees of accuracy. Bone scintigraphy has been utilized to detect skeletal metastases but is nonspecific and can be false positive in a number of benign etiologies.

Positron emission tomography with 18 F- fluorodeoxyglucose (FDG-PET) has been widely used in the evaluation of various malignancies. [4] It is useful in the staging of neoplasm, detection of secondary spread, evaluation of treatment response, and assessing posttherapy changes from residual or recurrent disease. The success of FDG-PET depends on enhanced glucose metabolism in malignant cells due to increased expression of cellular membrane glucose transporters (GLUT), especially GLUT-1 and hexokinase enzyme (HK-II) in the cells.

Early experience using FDG-PET in prostate cancer has demonstrated a relatively poor sensitivity because of low FDG accumulation in primary disease and its metastases.[5],[6],[7],[8] However, some studies and reviews have advocated that FDG-PET may be useful in the evaluation and management of patients with prostate cancer. [9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] The objective of the present study was to evaluate diagnostic utility of FDG-PET in confirmed cases of prostate cancer, especially with regard to the detection of osseous involvement of the disease by comparing the findings with the results of conventional skeletal scintigraphy.

 » Materials and Methods Top

We selected 16 patients (mean age, 67.2 years; age range, 55-83 years) with confirmed diagnosis of prostate cancer who were referred to our center for bone scan (BS) and subsequently for FDG-PET study for evaluation of the disease. Prior treatments were provided to 13 patients, which included (1) bilateral orchidectomy in 3 cases, (2) hormonal therapy in 1 case, (3) bilateral orchidectomy and hormonal therapy in 9 cases, and (4) 3 patients had not undergone any treatment. All the patients underwent bone scintigraphy as well as wholebody FDG-PET study at our center. Both studies were carried out within 1-week period for each patient [Table 1].
Table 1: Showing various categories of patients included in the study

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Bone scintigraphy was carried out between 3 and 4 h after intravenous injection of 900 MBq 99mTc-methylene diphosphonate and obtaining wholebody anterior and posterior skeletal images on the same film. Detailed images were also obtained when considered necessary for better viewing of suspected regions. A Dual-Head Gamma Camera (Picker International, Inc., Cleveland, OH, USA)th attached with parallel-hole high-resolution low-energy collimator was employed for the study. The images were evaluated by 2 experienced Nuclear Medicine Physicians for the presence of skeletal metastases.

For FDG-PET study, the patients were instructed to fast for at least 6 h and maintained blood sugar below 150 mg%. Imaging was performed 45-60 min after intravenous administration of 370-444 MBq (10-12 mCi) of FDG. Wholebody images were acquired on a dedicated PET instrument with full ring Bismuth Germanate (BGO) detectors (NXI, PETAdvance, GE Medical Systems, Milwaukee, WI, USA) in 2D mode. The scanner had axial spatial resolution of 5 mm FWHM (full width half maximum) and 14.5 cm field of view. At each bed position, emission as well as transmission data were acquired and 6-8 bed positions were covered starting from base of skull to distal thigh region. The skull was also included if indicated. Reconstruction of PET images was performed by using ordered subset expectation maximization algorithm and the images were processed with attenuation correction. The images were assessed visually by 2 experienced Nuclear Medicine Physicians after viewing the images in axial, sagittal, and coronal planes in conjunction with the clinical information and close correlation with other available imaging studies.

Skeletal abnormalities evident on FDG-PET study were compared with the findings of the BS on a lesion by lesion basis and vice-versa. Abnormal FDG accumulation in the extraosseous sites was also noted. Abnormal findings of both methods in 3 patients who have not received any management were critically reviewed to understand the role of individual modality in the evaluation of the disease.

 » Results Top

Results of BS and comparative FDG-PET findings are shown in [Table 2]. Totally, 198 lesions of osseous involvement were noted on BSs. A total of 97 skeletal lesions were evident on FDG-PET. In 2 patients, both the studies showed complete concordance for bone metastases. In one patient with normal BS, FDG-PET detected 3 sites of bone involvement. In the remaining 13 patients, FDG-PET showed less number of lesions than in the BS with varying concordance in various regions [Table 2].
Table 2: Comparative results of BS and FDG-PET for skeletal involvement of prostate cancer

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The findings of the FDG-PET demonstrating extra sites of the disease involvement are mentioned in [Table 3]. Five bone lesions that were observed in 2 patients were not evident on BS. Positive lymph nodes in the mediastinal, iliac, hilar, and inguinal regions were noted in 5, 2, 6, and 1 patients, respectively. Extensive bone marrow involvement was evident in 4 patients. Multiple liver lesions and lung lesion with multiple liver metastases were observed in 2 and 1 patients, respectively.
Table 3: Extra lesions identified by FDG-PET

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The description of the abnormalities evident on BS and FDG-PET in 3 untreated patients are separately given in [Table 4]. One patient (No. 2) had normal bone study. FDG-PET detected 3 bony lesions in addition to abnormal accumulation of FDG in the mediastinal right hilar nodes. In comparison to the skeletal scintigraphy, more number of bone lesions were evident on FDG-PET in patient No. 1. Another patient (No. 3) also showed almost the same number of bony involvement, but the site was different for a few lesions. All the patients had soft tissue involvement as evident on FDG-PET [Figure 1], [Figure 2], [Figure 3].
Figure 1: A 56-year-old male, known patient of adenocarcinoma prostate (Gleason's score 4+5 = 9) and prostate-specific antigen of 4861 ng/mL. (a) Note the extensive marrow involvement and large volume metastatic disease in the lung and liver in the FDG-PET study. (b) The bone scan in the same patient demonstrates features suggestive of superscan

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Figure 2: A 71-year-old male, a diagnosed patient of adenocarcinoma prostate with previous history of bilateral orchidectomy and present prostate-specific antigen of 101.2 ng/mL. (a) Bone scan shows foci of uptake in the right sacroiliac nodes, lumbar vertebra, and one of the left-sided upper ribs. (b) The FDG-PET study, in addition to the above-mentioned skeletal foci shows multiple foci of FDG uptake in the paraaortic, iliac lymph, and mediastinal nodes

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Figure 3: A 65-year-old male with history of bilateral orchidectomy 1 year previously and prostate-specific antigen of 437 ng/mL. Note the more extensive disease involvement shown in the FDG-PET compared with that shown by skeletal scintigraphy

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Table 4: Description of findings in 3 patients who did not undergo any treatment

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 » Discussion Top

Prostate cancer is one of the major health problems in elderly men. There is a need for reliable and accurate imaging methods for evaluating patients with prostate cancer. Attempts have been made to study the usefulness of PET imaging in prostate cancer and variable results were demonstrated with FDG. Effert et al performed a study using FDG-PET on 48 patients with untreated prostate cancer and concluded that it was not useful for differentiating prostate cancer and benign prostate hyperplasia. [9] The accumulation of FDG was positive only in 9 (19%) patients with prostate cancer, and it was not related to the clinical stage or histologic grade. Shreve et al demonstrated a sensitivity of 65% for the detection of skeletal involvement of prostate cancer using this technique. [6] In a study by Yeh et al, FDG-PET could identify only 20% of bone metastases in patients with prostate cancer. [10] In a study of 22 patients, Salminen et al found FDG-PET having only a limited value for clinical practice because of its low sensitivity and specificity. [19] The impact on the management was high in 46% cases, low in 41%, and there was no impact in 14% cases.

It has been shown that FDG-PET, however, may be useful to detect clinically advanced prostate cancer in patients with a higher Gleason score and serum PSA levels. [14] Increased localization of FDG may be due to enhanced rate of tumor growth in comparison to tumors showing low Gleason score. Seltzer et al demonstrated that FDG-PET could be better than 111In-Prostascint imaging in the detection of metastases in patients with higher serum PSA levels. [20] It has been well documented that FDG-PET is more useful to detect soft tissue metastases compared with those having skeletal involvement. [10],[14],[17] In a study by Jadvar et al., FDG-PET clearly localized nodal metastases, whereas CT showed nondiagnostic subcentimeter lymph nodes.[20]

In the present study, we made an attempt to evaluate the role of FDG-PET in a small number of prostate cancer patients who were in different stages of the disease and compared the findings with BS results. Putting together the data of all the patients, FDG-PET underestimated the extent of osseous metastases as compared with BS [Table 2]. A lower sensitivity of FDG-PET is reported for sclerotic skeletal metastases, particularly in prostate cancer, which predominantly produces this type of skeletal metastasis. The reason for this is still unclear, although a plausible explanation is that sclerotic metastases are relatively acellular and harbor only small amounts of viable tumor cells, and therefore have a low FDG uptake. However, we believe, this should be interpreted with caution, as we now know that metabolic response precedes osteoblastic response. This is further substantiated by the equivalent or even superior performance of FDG-PET imaging in patients who had not received any treatment previously. Similar concerns do exist in some of the previous studies that had examined patients with prostate carcinoma in its various stages, especially when they have been administered prior therapy. It is important to investigate whether this is the major reason for the apparent lower sensitivity of FDG-PET in these clinical settings. Although prostate cancer typically yields false-negative results on FDG-PET, it is worthwhile to investigate the clinical significance of FDG-PET-negative and BS-positive lesions in this group of patients.

Interestingly, FDG-PET clearly localized the nodal and soft tissue metastatic disease, a few skeletal lesions, and bone marrow disease, which were not localized by skeletal scintigaphy [Table 2]. Histopathologic correlation of the results could not be done for obvious ethical and practical reasons. The findings of FDG-PET and BS together in this group of patients at various stages of management enabled us to understand the extent of the disease with better sensitivity.

Looking at the findings of both the modalities in the various groups [Table 1] separately, we observed better lesion detection efficiency of FDG-PET in 3 untreated prostate cancer patients even for bone metastases [Table 4]. FDG-PET alone may probably play a very important role in the evaluation of freshly diagnosed patients. However, it needs further exploration in a larger number of patients.

Although this study was carried out with FDG, other PET radiopharmaceuticals, such as 11C-acetate, 11C-choline, 11C-methionine and 16beta- 18 F-fluoro-5alpha-dihydro-testosterone, have been found to be more advantageous than FDG for imaging evaluation of prostate cancer. [15],[21],[22],[23] The results of recent studies demonstrate the promising role of (18)F-fluoride PET-CT for the detection of bony metastases from prostate cancer. [24],[25],[26],[27] In a study [25] involving 38 patients, the sensitivity, specificity, and accuracy of PET-CT in the detection of bone metastases in prostate cancer was 81%, 93%, and 86% for (18)F fluoride and 74% (P = 0.12), 99% (P = 0.01), and 85%, respectively, for fluorocholine (FCH). (18)F FCH PET-CT led to a change in the management in 2 out of the 38 patients due to the early detection of bone marrow metastases. In another preclinical study [27] using small-animals, PET-CT scans were able to detect biologic activity of cells that induced an osteoblastic lesion 2 weeks earlier than plain radiographs. (18)F-FDG lesions strongly correlated with soft tissue measurements, whereas (18)F-fluoride ion activity correlated with bone volume measured on histomorphometric analysis (P < 0.005). The investigators concluded that both (18)F-FDG and (18)F-fluoride ion PET-CT scans can be useful tools in characterizing pure osteolytic and osteoblastic lesions induced by human prostate cancer cell lines. Combining 18 F-fluoride and FDG in a single scan is also interesting and has generated significant debate in the recent times with regard to their precise clinical use in the oncologic setting. [26],[27]

The present study results with subset analysis demonstrate that where the aforementioned PET tracers are not available, imaging with FDG can play a valuable complimentary role to the conventional skeletal scintigraphy in this malignancy, especially in the detection of bone marrow disease and soft tissue involvement. It can be particularly useful with regard to monitoring treatment response where FDG imaging can be superior to the conventional skeletal scintigraphy in demonstrating therapeutic response and is likely to be negative earlier than BS. Hence, in a comparison between the 2 modalities, the history of previous administration of therapy is essential for correct comparison of the 2 techniques. The other important aspect is the prediction of tumor biology. FDG-negative lesions are postulated to run an indolent course but this requires to be examined by further correlative studies between tumor uptake and Gleason score, and overall survival in these patients.

 » References Top

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2.Stamey TA, Yang N, Hay AR, McNeal JE, Freiha FS, Redwine E. Prostate-specific antigen as a serum marker for adenocarcinoma of the prostate. N Engl J Med 1987;317:909-16.  Back to cited text no. 2
3.Frank IN, Graham S Jr, Nabors WL. Urologic and male genital cancers. In: Holleb AI, Fink DJ, Murphy GP, editors. Clinical Oncology. Atlanta: American Cancer Society; 1991. p. 280-3.   Back to cited text no. 3
4.Digby W, Kelpper J. The current status of positron emission tomography. Radiol Manage 2000;22:37-40.  Back to cited text no. 4
5.Haseman MK, Reed NL, Rosenthal SA. Monoclonal antibody imaging of occult prostate cancer in patients with elevated prostate-specific antigen: Positron emission tomography and biopsy correlation. Clin Nucl Med 1996;21:704-13.  Back to cited text no. 5
6.Shreve PD, Grossman HB, Gross MD, Wahl RL. Metastatic prostate cancer: Initial findings of PET with 2-deoxy-2-[F-18]fluoro-D-glucose. Radiology 1996;199:751-6.   Back to cited text no. 6
7.Liu IJ, Zafar MB, Lai YH, Segall GM, Terris MK. Fluorodeoxyglucose positron emission tomography studies in diagnosis and staging of clinically organ-confined prostate cancer. Urology 2001;57:108-11.  Back to cited text no. 7
8.Shvarts O, Han KR, Seltzer M, Pantuck AJ, Belldegrun AS. Positron emission tomography in urologic oncology. Cancer Control 2002;9:335-42.  Back to cited text no. 8
9.Effert PJ, Bares R, Handt S, Wolff JM, Bull U and Jakse G. Metabolic imaging of untreated prostate cancer by positron emission tomography with 18 fluorine-labeled deoxyglucose. J Urol 1996;155:994-8.  Back to cited text no. 9
10.Yeh SD, Imbriaco M, Larson SM, Garza D, Zhang JJ, Kalaigian H, et al. Detection of bone metastases of androgen-independent prostate cancer by PET-FDG. Nucl Med Biol 1996;23:693-7.  Back to cited text no. 10
11.Agus DB, Golde DW, Sgouros G, Ballangrud A, Cordon-Cardo C, Scher HI. Positron emission tomography of a human prostate cancer xenograft: Association of changes in deoxyglucose accumulation with other measures of outcome following androgen withdrawal. Cancer Res 1998;58:3009-14.  Back to cited text no. 11
12.Heicappell R, Muller-Mattheis V, Reinhardt M, Vosberg H, Gerharz CD, Muller-Gartner H, et al. Staging of pelvic lymph nodes in neoplasms of the bladder and prostate by positron emission tomography with 2-[(18)F]-2-deoxy-D-glucose. Eur Urol 1999;36:582-7.  Back to cited text no. 12
13.Morris MJ, Akhurst T, Osman I, Nunez R, Macapinlac H, Siedlecki K, et al. Fluorinated deoxyglucose positron emission tomography imaging in progressive metastatic prostate cancer. Urology 2002;59:913-8.  Back to cited text no. 13
14.Oyama N, Akino H, Suzuki Y, Kanamaru H, Sadato N, Yonekura Y, et al. The increased accumulation of [ 18 F]fluorodeoxyglucose in untreated prostate cancer. Jpn J Clin Oncol 1999;29:623-9.  Back to cited text no. 14
15.Oyama N, Akino H, Kanamaru H, Suzuki Y, Muramoto S, Yonekura Y, et al. 11C-acetate PET imaging of prostate cancer. J Nucl Med 2002;43:181-6.  Back to cited text no. 15
16.Patel P, Cohade C, De Weese T, Wahl RL. Evaluation of metabolic activity of prostate gland with PET-CT. J Nucl Med 2002;43:119  Back to cited text no. 16
17.Sanz G, Robles JE, Gimenez M, Arocena J, Sanchez D, Rodriguez-Rubio F, et al. Positron emission tomography with 18 fluorine-labelled deoxyglucose: Utility in localized and advanced prostate cancer. BJU Int 1999;84:1028-31.  Back to cited text no. 17
18.Salminen E, Hogg A, Binns D, Frydenberg M, Hicks R. Investigations with FDG-PET scanning in prostate cancer show limited value for clinical practice. Acta Oncol 2002;41:425-9,   Back to cited text no. 18
19.Seltzer MA, Barbaric Z, Belldegrun A, Naitoh J, Dorey F, Phelps ME, et al. Comparison of helical computerized tomography, positron emission tomography and monoclonal antibody scans for evaluation of lymph node metastases in patients with prostate-specific antigen relapse after treatment for localized prostate cancer. J Urol 1999;162:1322-8.  Back to cited text no. 19
20.Jadvar H, Pinski JK, Conti PS. FDG PET in suspected recurrent and metastatic prostate cancer. Oncol Rep 2003;10:1485-8.  Back to cited text no. 20
21.Hara T, Kosaka N, Kishi H. PET imaging of prostate cancer using carbon-11-choline. J Nucl Med 1998;39:990-5.  Back to cited text no. 21
22.Nunez R, Macapinlac HA, Yeung HW, Akhurst T, Cai S, Osman I, et al. Combined 18 F-FDG and 11C-methionine PET scans in patients with newly progressive metastatic prostate cancer. J Nucl Med 2002;43:46-55.  Back to cited text no. 22
23.Larson SM, Morris M, Gunther I, Beattie B, Humm JL, Akhurst TA, et al. Tumor localization of 16beta- 18 F-fluoro-5alpha-dihydro-testosterone verses 18 F-FDG in patients with progressive, metastatic prostate cancer. J Nucl Med 2004;45:366-73.  Back to cited text no. 23
24.Beheshti M, Vali R, Waldenberger P, Fitz F, Nader M, Loidl W, et al. Detection of bone metastases in patients with prostate cancer by 18 F fluorocholine and 18 F fluoride PET-CT: A comparative study. Eur J Nucl Med Mol Imaging 2008;35:1766-74.  Back to cited text no. 24
25.Hsu WK, Virk MS, Feeley BT, Stout DB, Chatziioannou AF, Lieberman JR. Characterization of osteolytic, osteoblastic, and mixed lesions in a prostate cancer mouse model using 18 F-FDG and 18 F-fluoride PET/CT. J Nucl Med 2008;49:414-21.  Back to cited text no. 25
26.Iagaru A, Mittra E, Yaghoubi SS, Dick DW, Quon A, Goris ML, et al. Novel strategy for a cocktail 18 F-fluoride and 18 F-FDG PET/CT scan for evaluation of malignancy: Results of the pilot-phase study. J Nucl Med 2009;50:501-5.  Back to cited text no. 26
27.Basu S, Rao R. Combined (18)F-FDG and fluoride approach in PET/CT imaging: Is there a clinical future? J Nucl Med. 2010;51:165.  Back to cited text no. 27


  [Figure 1], [Figure 2], [Figure 3]

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