|Year : 2019 | Volume
| Issue : 3 | Page : 213-215
Upcoming role of prostate specific membrane antigen positron emission tomography-computed tomography in detecting occult metastases in prostate cancer
Parul Gupta, Rohini Mishra, Manoj Gupta, Partha Sarthi Choudhury
Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
|Date of Web Publication||20-Jun-2019|
Dr. Parul Gupta
Department of Nuclear Medicine and PET CT, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Prostate cancer (PCa) is the second most frequent malignancy in men. Most common sites of disease involvement other than the prostate gland include abdominopelvic lymph nodes and the skeleton. The detection of nodal metastases is of utmost importance to determine prognosis and choice of treatment in patients with PCa. Conventional imaging focuses on morphologic information and takes size criteria for decision-making. Early detection of metastases is further relevant in terms of prognosis and therapy management. Molecular imaging of PCa with Ga-68 prostate-specific membrane antigen (PSMA) positron emission tomography–computed tomography (PET-CT) has recently received significant attention and frequently used with a signature to PCa-specific remark. We presented the case of a 69-year-old male presenting with biochemical recurrence after undergoing surgery and in remission for about a year, where Ga-68 PSMA PET-CT identified additional sites of disease apart from the expected regional bed.
Keywords: Biochemical recurrence, conventional imaging, Ga-68 prostate-specific membrane antigen, positron emission tomography–computed tomography
|How to cite this article:|
Gupta P, Mishra R, Gupta M, Choudhury PS. Upcoming role of prostate specific membrane antigen positron emission tomography-computed tomography in detecting occult metastases in prostate cancer. Indian J Nucl Med 2019;34:213-5
|How to cite this URL:|
Gupta P, Mishra R, Gupta M, Choudhury PS. Upcoming role of prostate specific membrane antigen positron emission tomography-computed tomography in detecting occult metastases in prostate cancer. Indian J Nucl Med [serial online] 2019 [cited 2022 Jan 20];34:213-5. Available from: https://www.ijnm.in/text.asp?2019/34/3/213/260758
| Introduction|| |
Prostate cancer (PCa) is the second most common cancer and the sixth leading cause of cancer death in men worldwide. Abdominopelvic lymph nodal and skeletal metastases are the most common sites of disease involvement other than the prostate gland. Early detection of metastases is highly relevant in terms of prognosis and therapy management as even a single extrapelvic nodal metastasis turns PCa from a local to a systemic disease.
Conventional imaging focuses on morphologic information. Several studies promise accurate staging of primary PCa and restaging after biochemical recurrence with Ga-68 prostate-specific membrane antigen (PSMA) positron emission tomography–computed tomography (PET-CT). Ga-68 PSMA PET-CT is being increasingly used in the diagnosis and evaluation of PCa. Ga-68 PSMA PET-CT has the incremental value in identifying the disease outside the expected sites of involvement (pelvis), such as systemic lymph nodes (in the cervical region, mediastinum, etc.,) and bone and visceral metastases.
In our center, we routinely do Ga-68 PSMA PET-CT for PCa staging, recurrence, and response evaluation.
| Case Report|| |
A 69-year-old male with PCa underwent prostatectomy in May 2015. Histopathological examination revealed acinar adenocarcinoma with Gleason score 4 + 4 and Stage pT3a N1. Surgery was uneventful with low follow-up serum prostate-specific antigen (PSA) levels (<0.1 ng/ml). His PSA started rising slowly and had become 2.48 ng/ml in July 2017 with doubling time <6 months. Therefore, he was referred to us for Ga-68 PSMA PET-CT which revealed intensely PSMA-avid subcentimeter right internal mammary lymph node (1.1 cm × 0.6 cm and standardized uptake value – 11.5) with the mildly PSMA-expressing multiple bilateral subcentimeter lung ground-glass infiltrates and left internal iliac lymph node (<5 mm), as shown in [Figure 1], [Figure 2] and [Figure 3]. In view of rising PSA, positive Ga-68 PSMA PET-CT, and the fact that the sites of lesions were not amenable to cytology, it was discussed in multimodality meeting and hormonal treatment (degarelix) was started. Follow-up Ga-68 PSMA PET-CT after 3 months did not show any abnormal sites of PSMA uptake with insignificant serum PSA levels (0.062 ng/ml), proving the right internal mammary and left internal iliac lymph node as well as bilateral lung infiltrates to be a part of the primary disease process.
|Figure 1: (a) Axial sections of fusion positron emission tomography–computed tomography images revealing mildly fluorodeoxyglucose-avid left internal iliac lymph node in the scan in June 2017. (b) Axial sections of fusion positron emission tomography–computed tomography images revealing complete remission of the mildly fluorodeoxyglucose-avid left internal iliac lymph node in follow-up scan in November 2017|
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|Figure 2: (a) Axial sections of fusion positron emission tomography–computed tomography images revealing mildly fluorodeoxyglucose-avid left internal mammary lymph node in the scan in June 2017. (b) Axial sections of fusion positron emission tomography–computed tomography images revealing complete remission of the mildly fluorodeoxyglucose-avid left mammary lymph node in follow-up scan in November 2017|
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|Figure 3: (a) Axial sections of fusion positron emission tomography–computed tomography images revealing fluorodeoxyglucose-avid bilateral lung nodular infiltrates in the scan in June 2017. (b) Axial sections of fusion positron emission tomography–computed tomography images revealing complete remission of the fluorodeoxyglucose-avid bilateral lung nodular infiltrates in follow-up scan in November 2017|
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| Discussion|| |
The current published literature indicates that CT and magnetic resonance imaging perform similarly in the detection of pelvic lymph node metastasis (LNM) as, in either case, the lymph nodal involvement criteria is solely based on the size and shape. A threshold of 1 cm in the short axis for the oval lymph node and 0.8 cm for the round lymph node has been a recommended criterion for abnormal lymph node in morphological imaging despite the fact that a significant number of metastatic lymph nodes can be subcentimeter in size. To overcome these limitations, functional imaging techniques using radiopharmaceuticals and targets have been recently identified.
At least 30%–50% of patients with intermediate-to-high risk but clinically localized PCa, treated initially with a curative intent, will manifest biochemical failure, suggesting a combination of persistent local, periprostatic, regional (pelvic lymph nodes), or distant (i.e., systemic) disease.,,,, Despite higher doses of radiation and good surgical techniques, there is an increasing number of failures due to nonlocal treatment failure. If LNMs are present in a patient, curative treatment using radical prostatectomy or radical radiotherapy, directed only at the prostate, will inevitably be doomed to failure.
Molecular imaging of PCa with Ga-68 PSMA PET-CT has recently received significant attention and frequently used with a signature to PCa-specific remark. PSMA is a Type II membrane glycoprotein consisting of 750 amino acids. PSMA exhibits folate hydrolase/glutamate carboxypeptidase II enzymatic activity; however, its precise rolein vivo has not yet fully elucidated.In vitro its folate hydrolase activity has been associated with prostate carcinogenesis. In a large study in primary intermediate-to-high-risk PC, 68Ga-PSMA ligand imaging has been reported to clearly improve the detection of LNMs compared to morphological imaging, thus potentially allowing for a more tailored therapeutic concept. 68Ga-PSMA ligand PET imaging has been shown to increase the detection of metastatic sites even at low PSA values in comparison to conventional imaging or PET examination with other tracers.
One of the major challenges in the management of PCa is the identification of early physical (as opposed to biochemical) evidence of metastatic disease. In this particular case of interest, the sites of abnormally increased PSMA uptake such as right internal mammary lymph node and bilateral lung infiltrates were unusual sites of presentation and not amenable to histopathological correlation. The mildly PSMA-expressing left internal mammary lymph node was subcentimetric and hence not clearly metastatic following the structural imaging. Following three cycles of Firmagon (degarelix), a follow-up PSMA PET-CT did not show any abnormal sites of PSMA uptake with no significant serum PSA levels (0.062 ng/ml), proving the right internal mammary and left internal iliac lymph node as well as bilateral lung infiltrates to be a part of primary disease process.
Improvements in the predictive accuracy of imaging are of great interest in PCa. Conventional imaging has not been reliable in identifying LNM. Advances in imaging technology, such as the development of hybrid imaging systems such as PSMA PET-CT, which provide both structural and metabolic information, thus, have a promising future in identifying the disease recurrence, hence guarding the therapeutic planning.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jain S, Saxena S, Kumar A. Epidemiology of prostate cancer in India. Meta Gene 2014;2:596-605.
Hövels AM, Heesakkers RA, Adang EM, Jager GJ, Strum S, Hoogeveen YL, et al.
The diagnostic accuracy of CT and MRI in the staging of pelvic lymph nodes in patients with prostate cancer: A meta-analysis. Clin Radiol 2008;63:387-95.
Han M, Partin AW, Zahurak M, Piantadosi S, Epstein JI, Walsh PC, et al.
Biochemical (prostate specific antigen) recurrence probability following radical prostatectomy for clinically localized prostate cancer. J Urol 2003;169:517-23.
Chism DB, Hanlon AL, Horwitz EM, Feigenberg SJ, Pollack A. A comparison of the single and double factor high-risk models for risk assignment of prostate cancer treated with 3D conformal radiotherapy. Int J Radiat Oncol Biol Phys 2004;59:380-5.
Freedland SJ, Presti JC Jr., Amling CL, Kane CJ, Aronson WJ, Dorey F, et al.
Time trends in biochemical recurrence after radical prostatectomy: Results of the SEARCH database. Urology 2003;61:736-41.
Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A, et al.
Global cancer statistics, 2012. CA Cancer J Clin 2015;65:87-108.
Maurer T, Gschwend JE, Rauscher I, Souvatzoglou M, Haller B, Weirich G, et al.
Diagnostic efficacy of (68) Gallium-PSMA positron emission tomography compared to conventional imaging for lymph node staging of 130 consecutive patients with intermediate to high risk prostate cancer. J Urol 2016;195:1436-43.
Afshar-Oromieh A, Zechmann CM, Malcher A, Eder M, Eisenhut M, Linhart HG, et al.
Comparison of PET imaging with a (68) Ga-labelled PSMA ligand and (18) F-choline-based PET/CT for the diagnosis of recurrent prostate cancer. Eur J Nucl Med Mol Imaging 2014;41:11-20.
[Figure 1], [Figure 2], [Figure 3]