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The Detection of Bone Metastases in Patients with High-Risk Prostate Cancer: ^99mTc-MDP Planar Bone Scintigraphy, Single- and Multi-Field-of-View SPECT, ¹⁸F-Fluoride PET, and ¹⁸F-Fluoride PET/CT

¹ Department of Nuclear Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; ² Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; ³ Cyclotron Unit, Hadassah University Hospital, Jerusalem, Israel; and ⁴ Department of Urology, Meir Medical Center, Kfar Saba, Israel

Correspondence: For correspondence or reprints contact: Einat Even-Sapir, MD, PhD, Department of Nuclear Medicine, Tel Aviv Sourasky Medical Center, 6 Weizman St., Tel Aviv, 64239 Israel. E-mail: evensap{at}tasmc.health.gov.il

The aim of this study was to compare the detection of bone metastases by ^99mTc-methylene diphosphonate (^99mTc-MDP) planar bone scintigraphy (BS), SPECT, ¹⁸F-Fluoride PET, and ¹⁸F-Fluoride PET/CT in patients with high-risk prostate cancer. Methods: In a prospective study, BS and ¹⁸F-Fluoride PET/CT were performed on the same day in 44 patients with high-risk prostate cancer. In 20 of the latter patients planar BS was followed by single field-of-view (FOV) SPECT and in 24 patients by multi-FOV SPECT of the axial skeleton. Lesions were interpreted separately on each of the 4 modalities as normal, benign, equivocal, or malignant. Results: In patient–based analysis, 23 patients had skeletal metastatic spread (52%) and 21 did not. Categorizing equivocal and malignant interpretation as suggestive for malignancy, the sensitivity, specificity, positive predictive value, and negative predictive value of planar BS were 70%, 57%, 64%, and 55%, respectively, of multi-FOV SPECT were 92%, 82%, 86%, and 90%, of ¹⁸F-Fluoride PET were 100%, 62%, 74%, and 100%, and of ¹⁸F-Fluoride PET/CT were 100% for all parameters. Using the McNemar test, ¹⁸F-Fluoride PET/CT was statistically more sensitive and more specific than planar or SPECT BS (P < 0.05) and more specific than ¹⁸F-Fluoride PET (P < 0.001). SPECT was statistically more sensitive and more specific than planar BS (P < 0.05) but was less sensitive than ¹⁸F-Fluoride PET (P < 0.05). In lesion–based analysis, 156 lesions with increased uptake of ¹⁸F-Fluoride were assessed. Based on the corresponding appearance on CT, lesions were categorized by PET/CT as benign (n = 99), osteoblastic metastasis (n = 46), or equivocal when CT was normal (n = 11). Of the 156 ¹⁸F-Fluoride lesions, 81 lesions (52%), including 34 metastases, were overlooked with normal appearance on planar BS. SPECT identified 62% of the lesions overlooked by planar BS. ¹⁸F-Fluoride PET/CT was more sensitive and more specific than BS (P < 0.001) and more specific than PET alone (P < 0.001). Conclusion: ¹⁸F-Fluoride PET/CT is a highly sensitive and specific modality for detection of bone metastases in patients with high-risk prostate cancer. It is more specific than ¹⁸F-Fluoride PET alone and more sensitive and specific than planar and SPECT BS. Detection of bone metastases is improved by SPECT compared with planar BS and by ¹⁸F-Fluoride PET compared with SPECT. This added value of ¹⁸F-Fluoride PET/CT may beneficially impact the clinical management of patients with high-risk prostate cancer.

Key Words: PET-CT • ¹⁸F-Fluoride • SPECT • bone metastases • prostate cancer

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