Prospective head-to-head comparison of 11C-choline-PET/MR and 11C-choline-PET/CT for restaging of biochemical recurrent prostate cancer

  • Matthias Eiber
  • Isabel Rauscher
  • Michael Souvatzoglou
  • Tobias Maurer
  • Markus Schwaiger
  • Konstantin Holzapfel
  • Ambros J. Beer
Original Article



Whole-body integrated 11C-choline PET/MR might provide advantages compared to 11C-choline PET/CT for restaging of prostate cancer (PC) due to the high soft-tissue contrast and the use of multiparametric MRI, especially for detection of local recurrence and bone metastases.

Materials and methods

Ninety-four patients with recurrent PC underwent a single-injection/dual-imaging protocol with contrast-enhanced PET/CT followed by fully diagnostic PET/MR. Imaging datasets were read separately by two reader teams (team 1 and 2) assessing the presence of local recurrence, lymph node and bone metastases in predefined regions using a five-point scale. Detection rates were calculated. The diagnostic performance of PET/CT vs. PET/MR was compared using ROC analysis. Inter-observer and inter-modality variability, radiation exposure, and mean imaging time were evaluated. Clinical follow-up, imaging, and/or histopathology served as standard of reference (SOR).


Seventy-five patients qualified for the final image analysis. A total of 188 regions were regarded as positive: local recurrence in 37 patients, 87 regions with lymph node metastases, and 64 regions with bone metastases. Mean detection rate between both readers teams for PET/MR was 84.7% compared to 77.3% for PET/CT (p > 0.05). Local recurrence was identified significantly more often in PET/MR compared to PET/CT by team 1. Lymph node and bone metastases were identified significantly more often in PET/CT compared to PET/MR by both teams. However, this difference was not present in the subgroup of patients with PSA values ≤2 ng/ml.

Inter-modality and inter-observer agreement (K > 0.6) was moderate to substantial for nearly all categories. Mean reduction of radiation exposure for PET/MR compared to PET/CT was 79.7% (range, 72.6–86.2%). Mean imaging time for PET/CT was substantially lower (18.4 ± 0.7 min) compared to PET/MR (50.4 ± 7.9 min).


11C-choline PET/MR is a robust imaging modality for restaging biochemical recurrent PC and interpretations between different readers are consistent. It provides a higher diagnostic value for detecting local recurrence compared to PET/CT with the advantage of substantial dose reduction. Drawbacks of PET/MR are a substantially longer imaging time and a slight inferiority in detecting bone and lymph node metastases in patients with PSA values >2 ng/ml. Thus, we suggest the use of 11C-choline PET/MR especially for patients with low (≤2 ng/ml) PSA values, whereas PET/CT is preferable in the subgroup with higher PSA values.


Biochemical recurrence Prostate cancer Hybrid imaging 

Supplementary material

259_2017_3797_MOESM1_ESM.docx (14 kb)
Table 1S(DOCX 14 kb)
259_2017_3797_MOESM2_ESM.jpg (185 kb)
Figure 1SSingle-injection dual-imaging 11C-choline PET/CT and PET/MR examination in a 72-year-old patient with biochemical recurrence (PSA 1.2 ng/ml). PET of PET/CT (B, red arrow) and PET/MR (F, red arrow) both show a faint choline uptake in the left ramus inferior os pubis. As corresponding CT images show no clear anatomical correlate, the region was judged as probably (Score 4) and definitely (Score 5) without bone metastases by reader team 1 and 2, respectively. Fused axial and coronal PET/MR (G and H, red arrow) and corresponding MR-only sequences show a clear T2 hyperintense (E, red arrow), T1 hypointense (D, red arrow) lesion corresponding with the increased choline uptake. This was considered highly suggestive for a bone metastasis (score 1) by both reader teams. (JPEG 185 kb)


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Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • Matthias Eiber
    • 1
    • 2
  • Isabel Rauscher
    • 1
  • Michael Souvatzoglou
    • 1
  • Tobias Maurer
    • 3
  • Markus Schwaiger
    • 1
  • Konstantin Holzapfel
    • 4
  • Ambros J. Beer
    • 1
    • 5
  1. 1.Department of Nuclear Medicine, Technische Universität MünchenKlinikum rechts der IsarMunichGermany
  2. 2.Department of Molecular and Medical PharmacologyDavid Geffen School of Medicine at UCLALos AngelesUSA
  3. 3.Department of Urology, Technische Universität MünchenKlinikum rechts der IsarMunichGermany
  4. 4.Department of Radiology, Technische Universität MünchenKlinikum rechts der IsarMunichGermany
  5. 5.Department of Nuclear MedicineUlm UniversityUlmGermany

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