what can cause the prostate to light up on a pet scan
Br J Radiol. 2010 November; 83(995): 915–920.
Significance of incidental focal uptake in prostate on xviii-fluoro-2-deoxyglucose positron emission tomography CT images
Received 2009 Nov 4; Revised 2010 Feb 8; Accepted 2010 Feb 16.
Abstract
To evaluate the clinical significance of incidental focal prostate fluorodeoxyglucose (FDG) uptake, nosotros reviewed 18-F-FDG positron emission tomography (PET)/CT scans from 2003 to 2007 and selected cases with focal FDG uptake in prostate. Cases of known prostate cancer were excluded. The maximum standardised uptake value (SUVmax), site (central or peripheral) and design (discrete or ill-defined) of FDG uptake, calcification (present or absent-minded) and prostate volume (<thirty or ≥30 cc) were recorded. The PET/CT findings were correlated with serum prostate-specific antigen (PSA) levels, imaging studies, clinical follow-upwardly and biopsy. Of a total of 5119 cases, 63 (1.2%) demonstrated focal FDG uptake in prostate. Eight cases were lost to follow-upwards. Amongst the 55 cases with follow-upwardly, malignancy was confirmed past biopsy in iii (v.four%). The three malignant cases had SUVmax values of 3.three, iii.vi and two.iii, and all were noted in the peripheral portion of prostate; ii of these cases had a discrete FDG uptake pattern, none had calcification corresponding to the FDG uptake area and one had a prostatic volume greater than 30 cc. The mean SUVmax of 52 benign cases was 3.2 ± ane.seven and focal FDG uptake was noted in the peripheral portion in 34 (65%), twenty (38%) cases showed a discrete FDG uptake blueprint, 35 (67%) were accompanied by calcification and 32 (62%) had a prostatic volume greater than 30 cc. The majority of cases demonstrating focal FDG uptake in prostate were benign and no PET/CT finding could reliably differentiate beneficial from malignant lesions; however, when discrete focal FDG uptake without coincidental calcification is seen, particularly in the peripheral zone of the prostate, farther clinical evaluation is recommended.
xviii-Fluoro-2-deoxyglucose positron emission tomography (18-F-FDG PET) scanning has been used worldwide for staging and restaging of diverse malignancies, such as head and neck, breast, lung, oesophageal, colorectal and gynaecological cancers, lymphoma and melanoma [one–3]. In addition, reports have demonstrated a potential office of PET in cancer screening in asymptomatic participants. A PET scan can evaluate the whole body and allows for the early detection of hypermetabolic pre-cancerous or cancerous lesions [4, 5].
When PET images are obtained for cancer evaluation or preventative health check-up, incidental focal FDG uptake is sometimes noted in variable sites. Physiological uptake, benign lesions (such every bit inflammation) or unexpected cancers tin can be the crusade [half-dozen]. According to previous PET studies with big numbers of cases, second primary cancers were detected in one.2–4.viii% of patients with known cancer. The 2d tumours were constitute in variable sites such every bit thyroid, lung, colon, oesophagus, breast and parotid gland, amid others [7–9]. Patients with squamous cell carcinoma of the caput and cervix have a high take a chance of a second chief cancer of the lung or oesophagus. In head and neck cancer patients, the detection rate of a 2nd primary cancer by PET scan is reported to be as high as 18% [8]. In PET studies of good for you volunteers, Kojima et al [10] reported incidental cancer detection rates of 0.vii%, sensitivity of 70.6% and specificity of 94.0%. Of 2487 male person patients, two showed abnormal FDG uptake in the prostate; histological examination confirmed these to exist cancerous lesions. In another study [xi], incidental prostate cancer was rarely reported in cancer screening FDG PET studies of healthy men. Of 1629 men, 2 cases had incidental focal uptake in the prostate that was later confirmed as cancer.
From our experience, incidental focal FDG uptake in the prostate gland is encountered from time to time when reading PET/CT scans. To our knowledge, there are inadequate data on how to interpret such focal FDG uptake of prostate glands. The first aim of this newspaper was to examine the frequency of incidental focal FDG uptake in prostate on PET/CT scans performed for the evaluation of known cancer or preventative wellness check-up. The second aim was to determine the clinical significance of such FDG uptake in prostate. Lastly, we wanted to examine and compare the PET/CT features of prostate betwixt benign and malignant cases.
Methods and materials
Patients
A total of 5119 PET/CT scans of male patients performed for cancer evaluation or wellness check-up from November 2003 to October 2007 at our hospital were retrospectively reviewed. Amidst the 5119 PET/CT scans, 63 cases demonstrated incidental focal FDG uptake of the prostate gland. Cases where PET/CT scan was performed for staging or restaging of prostate cancer were excluded. Besides, cases without further study were excluded. Thus, a total of 55 cases demonstrating incidental focal FDG uptake of prostate with follow-up were included in this study.
The ethics commission of our establishment does not require patient consent for retrospective review of imaging studies.
The 18-F-FDG PET/CT scan
All patients fasted for at least six h before the PET/CT written report. 18-F-FDG was injected intravenously (370–555 MBq) and scanning began 60 min afterwards. None of the patients had blood glucose levels >130 mg dL–1 before the injection. No iv contrast agent was administered. Studies were acquired on combined PET/CT in-line systems, either Biograph Duo or Biograph Truepoint (Siemens Medical Solutions Knoxville, TN). The conquering time was ii–3 min per bed position. All patients were in a supine position with their arms raised. CT began at the orbitomeatal line and progressed to the upper thigh (130 kVp, 80 mA and 5 mm slice thickness; 120 kVp, 50 mA and 5 mm slice thickness). PET followed immediately over the aforementioned body region. The CT data were used for attenuation correction and images were reconstructed using a standard ordered-subset expectation maximisation (OSEM) algorithm. The axial spatial resolution was 6.5 mm or 4.v mm at the heart of the field of view.
Interpretation
All PET/CT images were reviewed at a workstation with fusion software (Syngo; Siemens) that provided multiplanar reformatted images and displayed PET images subsequently attenuation correction, CT images and PET/CT fusion images. The images were closely searched for focal uptake in prostate by two physicians who were board certified in both nuclear medicine and radiology.
Incidental focal FDG uptake was defined as discrete FDG activeness higher than the surrounding prostate gland on visual analysis. Images showing elongated FDG activity on coronal and sagittal views or FDG activity located in the heart of the prostate gland, are highly likely to event from prostatic urethral uptake and were excluded. The maximum standardised uptake value (SUVmax) in prostate was obtained from transaxial views.
Cases were grouped according to several variables: the site of FDG uptake (central or peripheral); the pattern of FDG uptake (detached or ill-defined) on axial view; calcification (present or absent); and prostate volume (<30 cc or ≥30 cc). The volume of the prostate gland was calculated from ultrasound or CT images. Long-axis diameters of the prostate were obtained from axial, sagittal and coronal views. The book of prostate was so estimated using the prostate volume ellipsoid formula: width (cm) × length (cm) × height (cm) × 0.52.
Method of diagnosis
PET/CT findings were correlated with results of biopsy, serum prostate-specific antigen (PSA) levels, imaging studies and urological examination. Patients with abnormally increased PSA levels (normal range 0–4 ng mL–one) or no PSA level checked within 3 months after the PET/CT scan had either imaging studies with a minimum 1 twelvemonth follow-upward or urological examination. Biopsy was performed in suspicious cases by the urologist. A total of 8 cases were confirmed past biopsy, 43 patients had their PSA level checked soon after the PET/CT scan, imaging studies such equally transrectal ultrasound (north = ten), CT (northward = ix), magnetic resonance (n = 2) or follow-upwardly PET/CT (n = 7) were obtained in 28 patients and 30 patients were examined by a urologist.
Results
Among 5119 PET/CT images, 63 cases (1.2%) demonstrated incidental focal FDG uptake of the prostate. Eight cases were excluded owing to loss at follow-up. Of a total of 55 cases (mean age 57±11 years; age range 31–83 years) included in this study, 23 PET/CT scans were performed for preventative wellness check-upwardly. The remaining 32 cases were performed for evaluation of known cancer (Table 1). Amongst the 55 cases, 3 (5.4%) were confirmed to be malignant and 52 were benign.
Table 1
Indications for performing positron emission tomography (PET)/CT scan
| Indication for PET/CT | Initial staging (n) | Restaging (n) | Total (n) |
| Head and cervix cancer | 3 | 4 | 7 |
| Lung cancer | four a | 4 | 8 |
| Stomach cancer | 3 a | i | four |
| Colorectal cancer | 4 | five | 9 |
| Hepatocellular carcinoma | 1 | 0 | 1 |
| Sarcoma | 0 | two | ii |
| Lymphoma | 1 | 0 | ane |
| Health check-upward | 0 | 0 | 23 |
Malignant lesions
Amongst the 55 cases, three (5.4%) cases were confirmed to exist adenocarcinoma by needle biopsy (Figure 1). FDG PET/CT features of the three cancers are described in Tabular array ii. In two cases at that place was focal calcification in the prostate, but the calcification did not correspond to the focal FDG uptake area.
Positron emission tomography (PET)/CT scan of a 74-yr-old human being performed for follow-upwardly of a known malignant sarcoma axial PET epitome, axial CT image, centric PET/CT fusion image. A detached focal fluorodeoxyglucose (FDG) uptake with a maximum standardised uptake value (SUVmax) of three.3 (arrow) was noted in the right marginal side of the prostate. Adenocarcinoma was confirmed by biopsy.
Table 2
Cases confirmed as malignancy (n = 3)
| Patient 1 | Patient 2 | Patient 3 | |
| Age (years) | 74 | 73 | 78 |
| Indication of PET/CT scan | Restaging, cancerous sarcoma in the nasal cavity | Initial staging, hypopharyngeal cancer | Initial staging, lung cancer |
| Gleason score | six (three + iii) | 8 (3 + five) | 8 (4 + 4) |
| PSA level (ng mL–i) | 2.82 | xvi.28 | >100 |
| SUVmax of prostate lesion | 3.3 | 3.half-dozen | 2.iii |
| Site of tumour | Periphery | Periphery | Periphery |
| FDG uptake pattern | Discrete | Detached | Ill-defined |
| Accompanying calcification | Absent-minded | Nowadays | Present |
| Prostate volume (cc) | 23.4 | 20.5 | 37.0 |
Benign lesions
Of the 55 cases, 52 (94.half dozen%) were beneficial. Four patients had increased PSA levels, but malignancy was excluded by further imaging studies and biopsy (Figure ii). In this report, 36 patients with PSA levels within the normal range and no abnormality on imaging or physical examination were considered benign. In 12 cases, PSA levels were non checked before long after the PET/CT examination, but no aberrant finding was noted in further imaging studies or on examination by the urologist and these were considered benign cases.
Positron emission tomography (PET)/CT scan of a 54-year-old man performed for restaging of known colon cancer. Axial PET epitome, axial CT image, axial PET/CT fusion image. There was no show of locoregional tumour recurrence or metastasis. Notwithstanding, a focal fluorodeoxyglucose (FDG) uptake with a maximum standardised uptake value (SUVmax) of three.nine (arrow) was noted in the correct lateral attribute of the prostate gland. The serum prostate-specific antigen level was increased to 14.06 ng mL–1. Needle biopsy confirmed nodular hyperplasia with focal chronic inflammation.
The mean SUVmax of the 52 benign lesions was iii.ii±i.seven (range 1.3–xiii.2). The features of the focal FDG uptake are shown in Table 3. In 34 cases (65%) calcification was present in the prostate gland and 26 cases showed calcification respective to the area of FDG uptake. The mean volume of the prostate gland was 37.7±17.1 cc (range xvi.0–81.nine cc).
Table 3
Cases confirmed as benign lesions (n = 52)
| Category | Number of cases |
| Site of FDG uptake | |
| Fundamental | 17 (33%) |
| Peripheral | 35 (67%) |
| FDG uptake pattern | |
| Discrete | twenty (38%) |
| Ill-defined | 32 (62%) |
| Accompanying calcification | |
| Present | 34 (65%) |
| Absent | 18 (35%) |
| Prostate volume (cc) | |
| <thirty | 20 (38%) |
| ≥30 | 32 (62%) |
| Full | 52 (100%) |
Word
Prostate cancer is the 2d most mutual cancer amid men. Of all the cancers diagnosed in 2002 worldwide, more than than i in 10 were located in the prostate [12]. Transrectal ultrasound, CT, MRI or bone scintigraphy are the generally recommended imaging studies in the staging of prostate cancer [13, fourteen]. However, 18-F-FDG PET has a limited role in the diagnosis or staging of urological malignancies including prostate cancer, bladder cancer and renal cell carcinoma. The detection of prostate cancer using FDG PET scanning is limited by urinary excretion of the radiotracer and the low metabolic activeness of prostate cancer [xv–eighteen]. In a study by Liu et al [nineteen], FDG PET was reported as having a sensitivity of 4.0% for tissue-confirmed prostate cancer.
Incidental focal FDG uptake in the prostate is a finding encountered every now and so and can be caused by both beneficial and malignant atmospheric condition. Among malignancies, adenocarcinoma is the most common histological type of prostate cancer and can appear as incidental focal FDG uptake; withal, other histological types can also be the cause. Rarely, neuroendocrine tumours with different biological behaviour from prostatic adenocarcinoma accept been reported. Compared with the prostatic adenocarcinoma, neuroendocrine tumours prove more intense FDG uptake [20]. Ho et al [21] reported loftier-grade urothelial carcinoma in prostate; a PET browse of this case likewise showed high FDG uptake with an SUVmax of 9.vii in the neoplasm located in the prostate. Beneficial conditions of prostate can also show increased FDG uptake. Focal or diffuse FDG uptake is reported in prostatitis [8, 22] or benign prostatic hyperplasia (BPH) [23–25].
Prostate cancer is confirmed by histological exam of a sample obtained by needle biopsy. PSA and digital rectal examination are useful screening tests in clinical exercise [fifteen]. In our report, the 3 incidental prostate cancer cases out of 55 (5.iv%) were all confirmed by biopsy; 2 cases had high PSA levels of sixteen ng mL–1 and >100 ng mL–ane. Oyama et al [26] reported that the caste of FDG uptake of primary prostate tumour was college on PET/CT scan in patients with college PSA levels than in those with lower PSA levels. Only exist warned, PSA levels tin can increase in benign weather condition such as BPH [27]. In this study, the PSA level was checked in 40 cases and ended as benign: the mean value of PSA was one.73±2.57 ng mL–1 (range 0.09–xiv.06 ng mL–1).
It is well established that prostate cancer commonly occurs in the peripheral zone of the gland [28]. In our study, all iii malignant cases had focal FDG uptake in the peripheral portion of the prostate gland. Of the 3 cancerous cases, one with advanced stage cancer showed heterogeneous FDG uptake in the peripheral portion and exhibited a definite outward jutting profile of the prostate gland in corresponding CT images. The other two malignant cases showed focal FDG uptake in the periphery portion abutting the margin of the prostate gland. Among the 52 benign cases, at that place was focal FDG uptake in the peripheral portion in approximately ii-thirds (67%). Strictly speaking, on a closer review of the PET/CT images, only ten cases (xix%) had focal FDG uptake in the peripheral portion adjacent to the margin of the gland. The remaining 25 cases were also localised in the peripheral zone of the gland, but uptake did not abut the gland margin. When focal FDG uptake is noted in the peripheral portion of the prostate gland, marginal location appears to be more suggestive of malignancy.
Of our 3 malignant cases, two showed a discrete design of FDG uptake. The remaining example had an ill-defined uptake blueprint on PET, but showed a definite jutting contour on accompanying CT. Large-sized tumours tin can alter the profile of the prostate gland and the CT portion of the PET/CT browse might be helpful in raising the detection rate of cancer [14].
Prostatic calcification is a common finding in older men and is encountered as calculus or intraluminal calcifications within atypical minor glandular proliferations [29]. According to one previous study, prostatic calcifications were noted in 47.2% of men under 50 years old and in 86% of men over l years old [30]. Shoskes et al [31] reported that prostatic calcification is associated with chronic prostatitis or chronic pelvic hurting syndrome; even so, prostatic calcification is non meaningful in asymptomatic healthy men. Our 3 prostate cancer patients were more lxx years old. Two patients had prostatic calcifications, but calcification foci did not coincide with the focal FDG uptake expanse. Of 34 benign cases with prostatic calcifications, the focal FDG uptake area was coincident with the calcification foci in about three-quarters; that is, focal FDG uptake lesions with coincident calcification were all confirmed as benign lesions.
Prostatic enlargement or BPH is common in older men and, although the definition varies slightly, a prostate volume approximately greater than or equal to thirty cc is considered enlargement [32]. BPH is characterised by nodular overgrowth of the epithelium and fibromuscular tissue inside the transition zone and periurethral surface area [33]. According to previous studies, BPH and prostate cancer cannot be reliably differentiated by FDG PET [23, 34]. Our written report included several cases with focal FDG uptake in the prostate gland that were later diagnosed as BPH on the basis of imaging or biopsy. Of the BPH cases, a case with SUVmax as high as 13.2 was included.
Of the 8 excluded cases, vi were patients from exterior the hospital referred only for the PET/CT scan. In the other two cases, therapeutic intervention for severe underlying diseases preceded whatever evaluation of the prostate lesion and follow-up was delayed. Prostate cancer is a very mutual malignancy in men, simply most patients with prostate cancer are diagnosed in the early stages and have a expert prognosis [35]. The preferred management of localised prostate cancer is non firmly established and many studies are currently under way to compare the effectiveness and potential dangers of agile intervention vs watchful waiting [36]. When incidental focal prostate uptake is detected in PET/CT of cancer patients, farther evaluation and treatment choice will be based on the severity of the underlying cancer, general condition, comorbidities, age and patient preference [37].
An important limitation of our study is pick bias. Not all of the cases had histological confirmation. PSA level, imaging study and clinical follow-up were used every bit a tool for making the diagnosis in a large number of cases. But the most authentic tool for diagnosing prostate cancer is biopsy. Also, evaluation was not performed in all cases with incidental focal FDG uptake on PET/CT. Eight cases missing follow-upward were excluded. This limitation originated from the retrospective report blueprint. For this reason, the accurate incidence or positive predictive value of incidental prostate cancer could not be obtained and might be college than our results indicate.
Conclusion
Focal FDG uptake of the prostate gland was incidentally noted in 1.2% of PET/CT scans performed for cancer staging or preventative health cheque-upwards in male person patients. Of the reported cases of incidental focal FDG uptake in prostate, v.iv% were confirmed every bit malignant. All malignant lesions were noted especially in the peripheral zone abutting the gland margin and did non have calcification in the area corresponding to FDG uptake. Most of the cases with incidental focal FDG uptake in the prostate were establish to be benign lesions. Merely 20% of beneficial lesions were noted in the peripheral zone abutting the gland margin. Screening for malignancy using a threshold SUVmax is difficult. Nevertheless, further evaluation would be prudent for discrete focal FDG uptake without coincidental calcification in the peripheral zone of prostate in elderly male patients, especially when the FDG uptake is abutting the gland margin.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3473727/
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