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CASE REPORT
Year : 2013  |  Volume : 28  |  Issue : 3  |  Page : 178-179  

Prostate cancer with lytic bone metastases: 18F-fluorodeoxyglucose positron emission tomography-computed tomography for diagnosis and monitoring response to medical castration therapy


Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication9-Oct-2013

Correspondence Address:
Rakesh Kumar
E 81, Ansari Nagar (East), AIIMS Campus, New Delhi 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.119545

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   Abstract 

Lytic bone metastases are rare in prostate cancer. We here present 18 fluorine fluorodeoxyglucose ( 18 F-FDG) positron emission tomography computed tomography (PET-CT) images of a 67-year-old male patient with lytic metastases from prostate cancer. Repeat 18 F-FDG PET-CT done 6 months later showed response to medical castration therapy. While the role of 18 F-FDG PET-CT for sclerotic bone metastases in prostate cancer remains controversial, it appears to be useful for detection and response assessment of lytic prostate cancer metastases.

Keywords: Bone, lytic, metastasis, prostate cancer, 18 fluorine fluorodeoxyglucose positron emission tomography-computed tomography


How to cite this article:
Sharma P, Karunanithi S, Dhull VS, Jain S, Bal C, Kumar R. Prostate cancer with lytic bone metastases: 18F-fluorodeoxyglucose positron emission tomography-computed tomography for diagnosis and monitoring response to medical castration therapy. Indian J Nucl Med 2013;28:178-9

How to cite this URL:
Sharma P, Karunanithi S, Dhull VS, Jain S, Bal C, Kumar R. Prostate cancer with lytic bone metastases: 18F-fluorodeoxyglucose positron emission tomography-computed tomography for diagnosis and monitoring response to medical castration therapy. Indian J Nucl Med [serial online] 2013 [cited 2019 Nov 20];28:178-9. Available from: http://www.ijnm.in/text.asp?2013/28/3/178/119545


   Introduction Top


Bone metastases are very common in prostate cancer with most of them being sclerotic in nature. Lytic bone metastases are very rare in prostate cancer. 18 fluorine fluorodeoxyglucose ( 18 F-FDG) positron emission tomography computed tomography (PET-CT) has low sensitivity in detection of sclerotic metastatic lesions of prostate cancer. However, in the detection of lytic prostate cancer metastasis, 18 F-FDG PET-CT is useful. In this context, we report a case of a patient having lytic skeletal metastases from prostate cancer where 18 F-FDG PET-CT was found to useful for detection and response assessment.


   Case report Top


A 67-year-old male patient presented with low grade fever of 3 months duration. During routine work-up, multiple lytic lesions were demonstrated on the radiograph of pelvis, suspicious for metastases. The patient underwent 18 F-FDG PET-CT for localization of the primary malignancy. 18 F-FDG PET-CT images revealed multiple lytic lesions involving almost entire skeleton, showing increased 18 F-FDG uptake (highest maximum standardized uptake value-6.9 [SUV max ]) [Figure 1]a and c. The prostate gland was enlarged and showed increased 18 F-FDG uptake along the periphery (SUV max -5.5) [Figure 1]e. Also noted were enlarged 18 F-FDG avid pelvic (SUV max -10.6) [Figure 1]g and retroperitoneal (SUV max -6.4) [Figure 1]i lymph nodes. Based on the 18 F-FDG PET-CT findings a diagnosis of carcinoma prostate with nodal and lytic skeletal metastases was made. The diagnosis was confirmed with transrectal ultrasound guided biopsy from prostate, which revealed prostatic adenocarcinoma with perineural invasion (Gleason score-9/10). The serum prostate specific antigen (PSA) was elevated (370 ng/ml; normal: 0-4 ng/ml).
Figure 1: Baseline 18 fluorine fluorodeoxyglucose (18F-FDG) positron emission tomography-computed tomography (PET-CT) images revealed multiple 18F-FDG avid lytic lesions involving almost entire skeleton (a, c, arrows). The prostate gland was enlarged and showed increased FDG uptake along the periphery (e, arrow) with enlarged FDG avid pelvic (g, arrow) and retroperitoneal (i, arrow) lymph nodes. Post-therapy 18F-FDG PET-CT revealed sclerotic non-FDG avid lesions replacing most of the lytic lesions (b, d, arrow) with reduction in size of the prostate gland and disappearance of peripheral FDG uptake (f, arrow). The pelvic and retroperitoneal lymph nodes also have disappeared (h, j)

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As lytic metastases are uncommon in prostate cancer, the patient underwent bone marrow biopsy to rule out any other malignant pathology. Bone marrow biopsy revealed metastatic carcinoma, positive for cytokeratin and PSA but negative for thyroid transcription factor-1, confirming the diagnosis. The patient was advised orchiectomy, which he refused. The patient was then put on medical castration therapy with combined androgen blockade. He was given luteinizing hormone releasing hormone agonist goserelin (10.8 mg subcutaneous injection every 3 months) along with non-steroidal anti-androgen bicalutamide (50 mg once daily orally).

Six months later the patient was referred for response assessment 18 F-FDG PET-CT. 18 F-FDG PET-CT revealed that most of the lytic lesions were replaced with sclerotic lesions with no significant 18 F-FDG uptake [Figure 1]b and d], except for lytic lesions in eighth dorsal vertebra, which showed mild 18 F-FDG uptake (SUV max -3.2). Also noted was a reduction in size of the prostate gland and disappearance of peripheral 18 F-FDG uptake (SUV max -1.1) [Figure 1]f. The pelvic and retroperitoneal lymph nodes also have disappeared [Figure 1]h and j. Thus, a diagnosis of minimal residual disease was made on 18 F-FDG PET-CT. This correlated with serum PSA levels, which showed drastic reduction (0.14 ng/ml; normal: 0-4 ng/ml).


   Discussion Top


While bone metastases are very common in prostate cancer, lytic metastases are rare. [1] They probably result from overproduction of parathyroid hormone related peptide by prostate cancer cells in vivo.[2] 18 F-FDG PET has low sensitivity for detection of sclerotic metastases in prostate cancer and is inferior to bone scintigraphy for this purpose. [3] In contrast, 18 F-FDG PET-CT is superior to bone scintigraphy for detection of lytic prostate cancer metastasis. [4] The 18 F-FDG uptake in prostate cancer cells is modulated by androgens. [5] The utility of 18 F-FDG PET-CT for monitoring response to anti-androgen therapy is still widely debated, but it is generally considered to be useful for differentiating active from healed lesions. [6],[7] Unfortunately, the low pre-therapy uptake of 18 F-FDG hampers response evaluation. [8] In the present case, 18 F-FDG PET-CT helped in making the primary diagnosis and demonstrated nodal and skeletal metastases. In addition, it helped in monitoring response to medical castration therapy by showing resolution of prostatic 18 F-FDG uptake, resolution of nodal lesions and sclerotic changes in almost all of skeletal lesions. [9] Therefore, it appears that 18 F-FDG PET-CT will be especially useful in prostate cancer patients with lytic skeletal metastasis.

 
   References Top

1.Jadvar H. Prostate cancer: PET with 18 F-FDG, 18 F- or 11C-acetate, and 18 F- or 11C-choline. J Nucl Med 2011;52:81-9.  Back to cited text no. 1
    
2.Rabbani SA, Gladu J, Harakidas P, Jamison B, Goltzman D. Over-production of parathyroid hormone-related peptide results in increased osteolytic skeletal metastasis by prostate cancer cells in vivo. Int J Cancer 1999;80:257-64.  Back to cited text no. 2
    
3.Shreve PD, Grossman HB, Gross MD, Wahl RL. Metastatic prostate cancer: Initial findings of PET with 2-deoxy-2- F-18 fluoro-D-glucose. Radiology 1996;199:751-6.  Back to cited text no. 3
    
4.Ozcan Kara P, Kara T, Kara Gedik G, Sari O, Sahin O. Comparison of bone scintigraphy and 18 F-FDG PET-CT in a prostate cancer patient with osteolytic bone metastases. Rev Esp Med Nucl 2011;30:94-6.  Back to cited text no. 4
    
5.Jadvar H, Xiankui L, Shahinian A, Park R, Tohme M, Pinski J, et al. Glucose metabolism of human prostate cancer mouse xenografts. Mol Imaging 2005;4:91-7.  Back to cited text no. 5
    
6.Oyama N, Akino H, Suzuki Y, Kanamaru H, Ishida H, Tanase K, et al. FDG PET for evaluating the change of glucose metabolism in prostate cancer after androgen ablation. Nucl Med Commun 2001;22:963-9.  Back to cited text no. 6
    
7.Morris MJ, Akhurst T, Osman I, Nunez R, Macapinlac H, Siedlecki K, et al. Fluorinated deoxyglucose positron emission tomography imaging in progressive metastatic prostate cancer. Urology 2002;59:913-8.  Back to cited text no. 7
    
8.Yu EY, Muzi M, Hackenbracht JA, Rezvani BB, Link JM, Montgomery RB, et al. C11-acetate and F-18 FDG PET for men with prostate cancer bone metastases: Relative findings and response to therapy. Clin Nucl Med 2011;36:192-8.  Back to cited text no. 8
    
9.Bellamy EA, Nicholas D, Ward M, Coombes RC, Powles TJ, Husband JE. Comparison of computed tomography and conventional radiology in the assessment of treatment response of lytic bony metastases in patients with carcinoma of the breast. Clin Radiol 1987;38:351-5.  Back to cited text no. 9
    


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