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Combined ¹⁸F-FDG and ¹¹C-Methionine PET Scans in Patients with Newly Progressive Metastatic Prostate Cancer

¹ Nuclear Medicine Service, Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York
² Cyclotron Core Facility, Sloan-Kettering Institute and Memorial Sloan-Kettering Cancer Center, New York, New York
³ Genitourinay Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
⁴ Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York

Metastatic prostate cancer may respond initially to hormone suppression, with involution of tumor sites, but ultimate tumor progression is inevitable. Our aim was to detect the proportion of bone and soft-tissue lesions that represent metabolically active tumor sites in patients with progressive metastatic prostate cancer. Methods: In a prospective study, we compared ¹⁸F-FDG and L-methyl-¹¹C-methionine (¹¹C-methionine) PET with conventional imaging modalities (CIM), which included the combination of ^99mTc-methylene diphosphonate scintigraphy, CT, or MRI. Twelve patients with prostate cancer, increasing levels of prostate-specific antigen (PSA), and at least 1 site (index lesion) with new or increasing disease on CIM were studied. The total numbers of soft-tissue and bone-tissue lesions, in a site-by-site comparison, were calculated for all imaging modalities. Results: The sensitivities of ¹⁸F-FDG PET and ¹¹C-methionine PET were 48% (167/348 lesions) and 72.1% (251/348 lesions), respectively, with CIM being used as the 100% reference (348/348). ¹¹C-Methionine PET identified significantly more lesions than ¹⁸F-FDG PET (P < 0.01). All 12 patients with progressive metastatic prostate cancer had at least 1 lesion site of active metabolism for ¹⁸F-FDG or ¹¹C-methionine, which could be used as an index lesion to monitor the metabolic response to therapy. A significant proportion of lesions (26%) had no detectable metabolism of ¹⁸F-FDG or ¹¹C-methionine. Although technical factors cannot be totally excluded, we believe that metabolically inactive sites may be necrotic or dormant. More than 95% (251/258) of metabolically active sites (72% of the total number of lesions detected by CIM) metabolize ¹¹C-methionine. ¹⁸F-FDG uptake is more variable, with 65% of metabolically active sites (48% of the total number of lesions detected by CIM). Conclusion: These findings reflect the different biologic characteristics of the lesions in a heterogeneous tumor such as prostate cancer and suggest that a time-dependent metabolic cascade may occur in advanced prostate cancer, with initial uptake of ¹¹C-methionine in dormant sites followed by increased uptake of ¹⁸F-FDG during progression of disease.

Key Words: PET • ¹⁸F-FDG • ¹¹C-methionine • bone scan • prostate cancer

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