Detection of Lymph-Node Metastases with Integrated [11C]Choline PET/CT in Patients with PSA Failure after Radical Retropubic Prostatectomy: Results Confirmed by Open Pelvic-Retroperitoneal Lymphadenectomy

doi:10.1016/j.eururo.2007.03.032

European Urology

Volume 52, Issue 2, August 2007, Pages 423-429

https://doi.org/10.1016/j.eururo.2007.03.032 Get rights and content

Abstract

Objectives

To prospectively evaluate the accuracy of integrated [¹¹C]choline-PET/CT in the diagnosis of lymph-node recurrence in prostate cancer patients with biochemical failure after surgery.

Methods

Since October 2002, 25 patients with biochemical recurrence (median PSA: 1.98 ng/ml), based on evidence of lymph-node metastases on [¹¹C]choline-PET/CT scan (21 cases) or conventional imaging (4 cases), were scheduled for either bilateral pelvic (12 cases) or both pelvic and retroperitoneal lymph-node dissection (13 patients).

Results

Sixty-three nodal sites were evaluated histologically. The mean number of nodes removed and positive nodes were 21.92 ± 16.91 (range: 4–74) and 8.84 ± 9.65 (range: 1–31), respectively. Of the four patients with negative [¹¹C]choline-PET/CT and positive magnetic resonance, none had nodal metastases. Nineteen of the 21 patients (90%) with positive [¹¹C]choline-PET/CT had nodal metastases of prostate adenocarcinoma at histologic evaluation. A lesion-based analysis showed that [¹¹C]choline-PET/CT sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 64%, 90%, 86%, 72%, and 77%, respectively. The mean maximum diameter of true positive metastases was larger than false-negative ones (15.0 vs. 6.3 mm; p = 0.0004).

Conclusions

[¹¹C]Choline-PET/CT is an accurate diagnostic tool for the detection of lymph-node metastases of recurrent prostate cancer. The low negative predictive value seems to depend on the limited capability of [¹¹C]choline-PET/CT to detect microscopic lesions. The high positive predictive value, even with low PSA values, provides a basis for further treatment decisions.

Introduction

Although an increase of prostate-specific antigen (PSA) after radical retropubic prostatectomy is the most sensitive tool for detecting prostate cancer recurrence, this measure cannot distinguish between a local, regional, or distant recurrence [1], [2]. Different imaging techniques are generally performed on patients with negative results. Digital rectal examination, transrectal ultrasound, and biopsies of the prostatic fossa are the most sensitive methods for detecting local recurrence, but they fail to detect local recurrence in 50% of cases, especially in patients with PSA < 1.0 ng/ml [3]. Although it has a low sensitivity, computed tomography (CT) is the primary imaging modality in the evaluation of nodal metastasis [4], [5]. The depiction of nodal disease relies on the fact that nodal size and the fraction of the CT-detected lymph-node metastases are generally correlated with PSA value [5]. The performance of magnetic resonance (MR) imaging is similar to that of CT. Bone scan scintigraphy is generally used to exclude the presence of bone metastases, but it is unlikely to be positive in patients with a serum PSA < 7 ng/ml [6].

Recently, the functional imaging modality positron emission tomography (PET), with the use of [¹¹C]choline, has been shown to be useful for restaging patients with an increasing PSA level after radical retropubic prostatectomy [7], [8], [9]. Preliminary data suggest that, in these patients, PET may accurately detect the presence of distant metastases in bone and lymph nodes and, although with less accuracy, of local recurrence, and is complementary to conventional imaging modalities, but with the advantage of restaging the disease in a single step [7]. In particular, integrated PET/CT imaging may accurately correlate abnormal metabolic changes derived by PET to anatomic structures derived by CT imaging.

The purpose of the present study was to prospectively evaluate the accuracy of integrated [¹¹C]choline-PET/CT in the detection of tumor lymph-node involvement, with the use of histologic results as the standard of reference, in patients undergoing retroperitoneal and/or pelvic lymph-node dissection because of a rising PSA level and isolated evidence of nodal recurrence.

Section snippets

Patients

This prospective study was conducted between October 2002 and June 2005. Patients with a PSA relapse after radical retropubic prostatectomy (PSA > 0.2 ng/ml) were considered eligible (n = 85). All patients underwent a digital rectal examination, [¹¹C]choline-PET/CT, bone scan, morphologic imaging (either CT or MR), and transrectal ultrasound (TRUS)-guided prostatic fossa biopsy to restage the disease. Patients with evidence of bone metastases, as detected by bone scintigraphy, and/or local

Results

A summary of the general patient characteristics is reported in Table 1. Mean PSA value at [¹¹C]choline-PET/CT analysis was 4.01 ± 5.4 ng/ml. Pelvic lymph-node dissection was performed on all 25 patients. Thirteen patients also underwent retroperitoneal lymphadenectomy because of positive [¹¹C]choline-PET/CT results in 8 patients and strong clinical suspicion of lymph-node metastases in the remaining 5 patients based on staging procedure.

Discussion

Currently, no accurate imaging modality is able to detect lymph-node metastases after radical retropubic prostatectomy in patients with low PSA level. Harisinghani et al [10] reported that the use of high-resolution MR nanoparticles allows the detection of small and otherwise undetectable lymph-node metastases in staging patients with prostate cancer before radical retropubic prostatectomy. The results of this study demonstrate that this technique can be successfully used to identify metastatic

Conclusions

This study shows that integrated [¹¹C]choline-PET/CT is a valuable diagnostic tool in patients with a PSA failure after radical retropubic prostatectomy, mainly because this modality is able to depict recurrent disease. Low NPV seems to depend on the limited capability of [¹¹C]choline-PET/CT to detect microscopic or small-volume lesions. The high PPV of [¹¹C]choline-PET/CT, even in patients with low PSA values, provides a basis for further treatment decisions. Patients with a negative PET scan

Conflicts of interest

There were no sources of funding for the work.

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Detection rates of different imaging techniques depend on the PSA level at the time of imaging. Recent advanced imaging techniques may detect the localization of the recurrence, even when the PSA levels are still very low.
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A 11C-choline positron emission tomography/computed tomography (PET/CT) scan is used for restaging prostate cancer (PCa) patients with biochemical recurrence (BCR). Only a few reports have focused on the correlation between PET/CT and nodal relapse location at pathologic examination.
To assess the accuracy of PET/CT in predicting the site of nodal relapses in patients undergoing pelvic and/or retroperitoneal salvage lymph node dissection (sLND).
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Prostate CancerDetection of Lymph-Node Metastases with Integrated [11C]Choline PET/CT in Patients with PSA Failure after Radical Retropubic Prostatectomy: Results Confirmed by Open Pelvic-Retroperitoneal Lymphadenectomy

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Results

Discussion

Conclusions

Conflicts of interest

Eur Urol

Eur Urol

Urology

J Urol

J Urol

Semin Oncol

Eur Urol

Diagnosis of local recurrence after radical prostatectomy

BJU Int

Radionuclide bone scintigraphy in patients with biochemical recurrence after radical prostatectomy: when is it indicated?

BJU Int

Prostate Cancer
Detection of Lymph-Node Metastases with Integrated [¹¹C]Choline PET/CT in Patients with PSA Failure after Radical Retropubic Prostatectomy: Results Confirmed by Open Pelvic-Retroperitoneal Lymphadenectomy