18F Choline PET/CT in the Preoperative Staging of Prostate Cancer in Patients with Intermediate or High Risk of Extracapsular Disease: A Prospective Study of 130 Patients

Published Online:https://doi.org/10.1148/radiol.09090413

Fluorocholine PET/CT changed the therapeutic care of 20% of patients at high risk for extracapsular extension.

Purpose

To prospectively evaluate the potential value of fluorocholine (FCH) positron emission tomography (PET)/computed tomography (CT) in the preoperative staging of patients with prostate cancer who had intermediate or high risk of extracapsular disease.

Materials and Methods

Institutional review board approval and written informed consent were obtained. Overall, 132 patients with prostate cancer (mean age, 63 years ± 7 [standard deviation]) were enrolled between October 2003 and June 2008. Two patients were subsequently excluded. In 111 patients, radical prostatectomy with extended pelvic lymph node (LN) dissection was performed. Patients were categorized into groups with intermediate (n = 47) or high (n = 83) risk of extracapsular extension on the basis of their Gleason scores and prostate specific antigen levels. Imaging was performed with an integrated PET/CT system after injection of 4.07 MBq FCH per kilogram of body weight with acquisition of dynamic images in the pelvis and whole-body images. Statistical analysis was performed on a per-patient basis.

Results

Significant correlation was found between sections with the highest FCH uptake and sextants with maximal tumor infiltration (r = 0.68; P = .0001). Overall, 912 LNs were histopathologically examined. A per-patient analysis revealed the sensitivity, specificity, and positive and negative predictive values of FCH PET/CT in the detection of malignant LNs were 45%, 96%, 82%, and 83%, respectively. For LN metastases greater than or equal to 5 mm in diameter, sensitivity, specificity, and positive and negative predictive values were 66%, 96%, 82%, and 92%, respectively. In 13 patients, 43 bone metastases were detected. Early bone marrow infiltration was detected with only FCH PET in two patients. FCH PET/CT led to a change in therapy in 15% of all patients and 20% of high-risk patients.

Conclusion

FCH PET/CT could be useful in the evaluation of patients with prostate cancer who are at high risk for extracapsular disease, and it could be used to preoperatively exclude distant metastases.

© RSNA, 2010

Supplemental material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09090413/-/DC1

References

  • 1 Jemal A , Murray T , Ward E , et al. . Cancer statistics, 2005. CA Cancer J Clin 2005;55(1):10–30.
  • 2 Hricak H , Schöder H , Pucar D , et al. . Advances in imaging in the postoperative patient with a rising prostate-specific antigen level. Semin Oncol 2003;30(5):616–634.
  • 3 Abuzallouf S , Dayes I , Lukka H . Baseline staging of newly diagnosed prostate cancer: a summary of the literature. J Urol 2004;171(6 pt 1):2122–2127.
  • 4 Hricak H , Choyke PL , Eberhardt SC , Leibel SA , Scardino PT . Imaging prostate cancer: a multidisciplinary perspective. Radiology 2007;243(1):28–53.
  • 5 Effert PJ , Bares R , Handt S , Wolff JM , Büll U , Jakse G . Metabolic imaging of untreated prostate cancer by positron emission tomography with 18fluorine-labeled deoxyglucose. J Urol 1996;155(3):994–998.
  • 6 Heicappell R , Müller-Mattheis V , Reinhardt M , 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(6):582–587.
  • 7 Hofer C , Laubenbacher C , Block T , Breul J , Hartung R , Schwaiger M . Fluorine-18-fluorodeoxyglucose positron emission tomography is useless for the detection of local recurrence after radical prostatectomy. Eur Urol 1999;36(1):31–35.
  • 8 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(1):108–111.
  • 9 Morris MJ , Akhurst T , Osman I , et al. . Fluorinated deoxyglucose positron emission tomography imaging in progressive metastatic prostate cancer. Urology 2002;59(6):913–918.
  • 10 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(3):751–756.
  • 11 Langsteger W , Heinisch M , Fogelman I . The role of fluorodeoxyglucose, 18F-dihydroxyphenylalanine, 18F-choline, and 18F-fluoride in bone imaging with emphasis on prostate and breast. Semin Nucl Med 2006;36(1):73–92.
  • 12 Cimitan M , Bortolus R , Morassut S , et al. . [18F]fluorocholine PET/CT imaging for the detection of recurrent prostate cancer at PSA relapse: experience in 100 consecutive patients. Eur J Nucl Med Mol Imaging 2006;33(12):1387–1398.
  • 13 Reske SN , Blumstein NM , Neumaier B , et al. . Imaging prostate cancer with 11C-choline PET/CT. J Nucl Med 2006;47(8):1249–1254.
  • 14 Kwee SA , Wei H , Sesterhenn I , Yun D , Coel MN . Localization of primary prostate cancer with dual-phase 18F-fluorocholine PET. J Nucl Med 2006;47(2):262–269.
  • 15 Schmid DT , John H , Zweifel R , et al. . Fluorocholine PET/CT in patients with prostate cancer: initial experience. Radiology 2005;235(2):623–628.
  • 16 Schiavina R , Scattoni V , Castellucci P , et al. . 11C-choline positron emission tomography/computerized tomography for preoperative lymph-node staging in intermediate-risk and high-risk prostate cancer: comparison with clinical staging nomograms. Eur Urol 2008;54(2):392–401.
  • 17 Testa C , Schiavina R , Lodi R , et al. . Prostate cancer: sextant localization with MR imaging, MR spectroscopy, and 11C-choline PET/CT. Radiology 2007;244(3):797–806.
  • 18 Häcker A , Jeschke S , Leeb K , et al. . Detection of pelvic lymph node metastases in patients with clinically localized prostate cancer: comparison of [18F]fluorocholine positron emission tomography-computerized tomography and laparoscopic radioisotope guided sentinel lymph node dissection. J Urol 2006;176(5):2014–2018 ; discussion 2018–2019.
  • 19 Scher B , Seitz M , Albinger W , et al. . Value of 11C-choline PET and PET/CT in patients with suspected prostate cancer. Eur J Nucl Med Mol Imaging 2007;34(1):45–53.
  • 20 Goldstein NS , Bégin LR , Grody WW , Novak JM , Qian J , Bostwick DG . Minimal or no cancer in radical prostatectomy specimens: report of 13 cases of the “vanishing cancer phenomenon”. Am J Surg Pathol 1995;19(9):1002–1009.
  • 21 Vassiliev D , Krasikova R , Kutznetsova O , Federova O , Nader M . Simple HPLC method for the detection of N,N-dimethylaminoethanol in the preparation of [N-methyl-11C] choline. Eur J Nucl Med Mol Imaging 2003;30(suppl):342P.
  • 22 Schröder FH , Roach M , Scardino P . Clinical decisions: management of prostate cancer. N Engl J Med 2008;359(24):2605–2609.
  • 23 Harisinghani MG , Barentsz J , Hahn PF , et al. . Noninvasive detection of clinically occult lymph-node metastases in prostate cancer. N Engl J Med 2003;348(25):2491–2499.
  • 24 Breeuwsma AJ , Pruim J , Jongen MM , et al. . In vivo uptake of [11C]choline does not correlate with cell proliferation in human prostate cancer. Eur J Nucl Med Mol Imaging 2005;32(6):668–673.
  • 25 Zheng QH , Gardner TA , Raikwar S , et al. . [11C]Choline as a PET biomarker for assessment of prostate cancer tumor models. Bioorg Med Chem 2004;12(11):2887–2893.
  • 26 de Jong IJ , Pruim J , Elsinga PH , Vaalburg W , Mensink HJ . Preoperative staging of pelvic lymph nodes in prostate cancer by 11C-choline PET. J Nucl Med 2003;44(3):331–335.
  • 27 Husarik DB , Miralbell R , Dubs M , et al. . Evaluation of [(18)F]-choline PET/CT for staging and restaging of prostate cancer. Eur J Nucl Med Mol Imaging 2008;35(2):253–263.
  • 28 Conti M . State of the art and challenges of time-of-flight PET. Phys Med 2009;25(1):1–11.
  • 29 Hricak H , Dooms GC , Jeffrey RB , et al. . Prostatic carcinoma: staging by clinical assessment, CT, and MR imaging. Radiology 1987;162(2):331–336.
  • 30 Platt JF , Bree RL , Schwab RE . The accuracy of CT in the staging of carcinoma of the prostate. AJR Am J Roentgenol 1987;149(2):315–318.
  • 31 Golimbu M , Morales P , Al-Askari S , Shulman Y . CAT scanning in staging of prostatic cancer. Urology 1981;18(3):305–308.
  • 32 Rørvik J , Halvorsen OJ , Albrektsen G , Haukaas S . Lymphangiography combined with biopsy and computer tomography to detect lymph node metastases in localized prostate cancer. Scand J Urol Nephrol 1998;32(2):116–119.
  • 33 Wolf JS , Cher M , Dall’era M , Presti JC , Hricak H , Carroll PR . The use and accuracy of cross-sectional imaging and fine needle aspiration cytology for detection of pelvic lymph node metastases before radical prostatectomy. J Urol 1995;153(3 pt 2):993–999.
  • 34 Beheshti M , Vali R , Waldenberger P , et al. . Detection of bone metastases in patients with prostate cancer by 18F fluorocholine and 18F fluoride PET-CT: a comparative study. Eur J Nucl Med Mol Imaging 2008;35(10):1766–1774.
  • 35 Beheshti M , Vali R , Waldenberger P , et al. . The use of F-18 choline PET in the assessment of bone metastases in prostate cancer: correlation with morphological changes on CT. Mol Imaging Biol, 2009;11(6):446–454.
  • 36 Beheshti M , Vali R , Langsteger W . [18F]fluorocholine PET/CT in the assessment of bone metastases in prostate cancer. Eur J Nucl Med Mol Imaging 2007;34(8):1316–1317; author reply 1318–1319.

Article History

Received March 11, 2009; revision requested April 9; revision received August 4; accepted September 18; final version accepted October 20.
Published online: Feb 8 2010
Published in print: Mar 2010