Elsevier

European Urology

Volume 42, Issue 1, July 2002, Pages 18-23
European Urology

Visualization of Prostate Cancer with 11C-Choline Positron Emission Tomography

https://doi.org/10.1016/S0302-2838(02)00129-XGet rights and content

Abstract

Background and Objective: Visualization of prostate cancer with positron emission tomography (PET) using 2-[18F]-2-deoxy-D-glucose (FDG) as radiopharmaceutical is limited by the low uptake of FDG in the tumor and by radioactivity excreted into the bladder. More specific PET radiopharmaceuticals would be welcome. Carbon-11 labeled choline (CHOL) is a new radiopharmaceutical potentially useful for tumor imaging as it is incorporated in the cell membranes as phosphatidylcholine. We prospectively studied the visualization of prostate cancer using CHOL PET.

Methods: A total of 25 consecutive patients with histologically proven prostate cancer and five patients with a benign prostate were included. PET images were performed with an ECAT HR+ using 400 MBq CHOL. Data acquisition was started at 5 minutes post-injection. Attenuation-corrected images were evaluated visually. Standardized uptake values (SUV) were calculated of the normal prostate gland and of the prostate tumor tissue.

Results: The normal prostate was visualized with a mean SUV of 2.3 (range 1.3–3.2). The primary tumor could be visualized with a mean SUV of 5.0 (range 2.4–9.5). Lymph node metastases >5 mm could be identified. Non-specific uptake of CHOL was noticed in the intestines. Little to no radioactivity in the bladder was observed.

Conclusion: Carbon-11-choline is avidly taken up in prostate cancer, both primary tumor and lymph node metastases, in the virtual absence of urinary radioactivity. These results confirm the early results obtained by others and permit further clinical research on the value of CHOL PET as a metabolic imaging technique in areas where conventional imaging have a limited sensitivity.

Introduction

Positron emission tomography (PET) using 2-[18F]-2-deoxy-D-glucose (FDG) as a radiopharmaceutical has been shown to be an accurate technique for tumor detection, staging and monitoring of therapy in a number of malignant tumors [1]. So far, the clinical experience with FDG-PET in prostate cancer is limited for two reasons: the uptake of FDG in prostate cancer is low and FDG is rapidly excreted in urine, causing an accumulation of activity in the bladder [2], [3], [4], [5].

Carbon-11 labeled choline (CHOL) has recently been reported as a new PET radiopharmaceutical for tumor detection [6]. Choline is one of the components of phosphatidylcholine, an essential element of phospholipids in the cell membrane [7]. Malignant tumors may show a high proliferation and increased metabolism of cell membrane components, which will lead to an increased uptake of choline [8]. First results with CHOL PET in patients with (advanced) prostate cancer showed visualization of the primary tumor and of known metastatic sites [9], [10]. In order to validate these preliminary results and further define the potential of CHOL PET, we studied CHOL PET prospectively in patients with prostate cancer.

Section snippets

Patients

A total of 25 consecutive patients with histologically proven adenocarcinoma of the prostate participated in this study. The primary tumor was staged clinically according to palpatory findings and transrectal ultrasound. An MRI or a CT was performed to assess lymph node metastases pre-operatively. Patients with T4 tumors and/or known distant metastases were excluded. In addition, the uptake of CHOL in the normal prostate was studied in five patients with a bladder carcinoma who underwent

Visualization of the normal prostate

Physiological uptake of the radiopharmaceutical was noticed in the small intestine in all subjects studied. In three patients, a moderate non-specific accumulation of radioactivity was seen in the bladder region. The uptake of CHOL in the prostate was measured in five patients who underwent cystectomy for bladder tumors with a mean SUV of 2.3 (range 1.3–3.2). Histology of the operation specimens excluded malignancy and showed benign hyperplasia in four patients (Table 1).

Visualization of prostate cancer

In the prostate tumor,

Discussion

The most widely used PET radiopharmaceutical in oncology is FDG. However, FDG shows major drawbacks in prostate cancer. As the uptake of FDG in prostate cancer is low, the differentiation between cancer and benign hyperplasia is not possible using FDG-PET [5]. Moreover, the radiotracer is excreted into the bladder. High levels of radioactivity in the bladder interfere with radioactivity accumulation in the prostate area and can mask small tumors or metastases in the pelvic area. Bladder

Conclusion

Carbon-11-choline is avidly taken up in prostate cancer, both primary tumor and lymph node metastases, in the virtual absence of urinary radioactivity. These results confirm the early results obtained by others and permit further clinical research on the value of CHOL PET as a metabolic imaging technique in areas where conventional imaging have a limited sensitivity.

References (22)

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