Liver metastases from prostate cancer at 11C-Choline PET/CT: a multicenter, retrospective analysis

  • Pietro Ghedini
  • I. Bossert
  • L. Zanoni
  • F. Ceci
  • T. Graziani
  • P. Castellucci
  • V. Ambrosini
  • F. Massari
  • E. Nobili
  • B. Melotti
  • A. Musto
  • S. Zoboli
  • L. Antunovic
  • M. Kirienko
  • A. Chiti
  • C. Mosconi
  • A. Ardizzoni
  • R. Golfieri
  • S. Fanti
  • C. Nanni
Original Article
  • 155 Downloads

Abstract

Aim

During our daily clinical practice using 11C-Choline PET/CT for restaging patients affected by relapsing prostate cancer (rPCa) we noticed an unusual but significant occurrence of hypodense hepatic lesions with a different tracer uptake. Thus, we decided to evaluate the possible correlation between rPCa and these lesions as possible hepatic metastases.

Materials and methods

We retrospectively enrolled 542 patients diagnosed with rPCa in biochemical relapse after a radical treatment (surgery and/or radiotherapy). Among these, patients with a second tumor or other benign hepatic diseases were excluded. All patients underwent 11C-Choline PET/CT during the standard restaging workup of their disease. We analyzed CT images to evaluate the presence of hypodense lesions and PET images to identify the relative tracer uptake. In accordance to the subsequent oncological history, five clinical scenarios were recognized [Table 1]: normal low dose CT (ldCT) and normal tracer distribution (Group A); evidence of previously unknown hepatic round hypodense areas at ldCT with normal rim uptake (Group B); evidence of previously known hepatic round hypodense areas at ldCT stable over time and with normal rim uptake (Group C); evidence of previously known hepatic round hypodense areas at ldCT, in a previous PET/CT scan, with or without rim uptake and significantly changing over time in terms of size and/or uptake (Group D); evidence of hepatic round hypodense areas at ldCT with or without rim uptake confirmed as prostate liver metastases by histopathology, triple phase ceCT, ce-ultra sound (CEUS) and clinical/biochemical evaluation (Group E). We evaluated the correlation with PSA level at time of scan, rim SUVmax and association with local relapse or non-hepatic metastases (lymph nodes, bone, other parenchyma).

Results

Five hundred and forty-two consecutive patients were retrospectively enrolled. In 140 of the 542 patients more than one 11C-choline PET/CT had been performed. A total of 742 11C-Choline PET/CT scans were analyzed. Of the 542 patients enrolled, 456 (84.1%) had a normal appearance of the liver both at ldCT and PET (Group A). 19/542 (3,5%) belonged to Group B, 13/542 (2.4%) to Group C, 37/542 (6.8%) to Group D and 18/542 (3.3%) to Group E. Mean SUVmax of the rim was: 4.5 for Group B; 4.2 for Group C; 4.8 for Group D; 5.9 for Group E. Mean PSA level was 5.27 for Group A, 7.9 for Group B, 10.04 for Group C, 10.01 for Group D, 9.36 for Group E. Presence of positive findings at 11C-Choline PET/CT in any further anatomical area (local relapse, lymph node, bone, other extra hepatic sites) correlated with an higher PSA (p = 0.0285). In both the univariate and multivariate binary logistic regression analyses. PSA, SUVmax of the rim, local relapse, positive nodes were not associated to liver mets (Groups D-E) (p > 0.05). On the contrary, a significant correlation was found between the presence of liver metG (group D-E) and bone lesions (p= 0.00193).

Conclusion

Our results indicate that liver metastases in relapsing prostate cancer may occur frequently. The real incidence evaluation needs more investigations. In this case and despite technical limitations, Choline PET/CT shows alterations of tracer distribution within the liver that could eventually be mistaken for simple cysts but can be suspected when associated to high trigger PSA, concomitant bone lesions or modification over time. In this clinical setting an accurate analysis of liver tracer distribution (increased or decreased uptake) by the nuclear medicine physician is, therefore, mandatory.

Keywords

Prostate cancer Liver secondary lesions Visceral metastases 11C-Choline PET/CT 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Mottet N, Bellmunt J, Briers E, van den Bergh RCN, Bolla M, van Casteren NJ, et al. Guidelines on prostate cancer. Eur Assoc Urol 2015.Google Scholar
  2. 2.
    Mottet N, Bellmunt J, Bolla M, Cornford P, et al. EAU-ESTRO-SIOG guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent. Eur Urol. 2017;71:618–29.CrossRefPubMedGoogle Scholar
  3. 3.
    Siegel R, Miller K. Jemal a (2016) cancer statistics, et al. CA Cancer J Clin. 2016;66:7–30.CrossRefPubMedGoogle Scholar
  4. 4.
    Boorjian S, Eastham J, Graefen M, Zorn K. A critical analysis of the long-term impact of radical prostatectomy on cancer control and function outcomes. Eur Urol. 2012;61(4):664–75.CrossRefPubMedGoogle Scholar
  5. 5.
    Briganti A, Karnes RJ, Gandaglia G, Spahn M, Gontero P, Tosco L, et al. Natural history of surgically treated high-risk prostate cancer. Urol Oncol. 2015;33(4):163.e7–13.CrossRefGoogle Scholar
  6. 6.
    Punnen S, Cooperberg MR, D’Amico AV, Karakiewicz PI, Moul JW, Scher HI, et al. Management of biochemical recurrence after primary treatment of prostate cancer: a systematic review of the literature. Eur Urol. 2013;64(6):905–15.CrossRefPubMedGoogle Scholar
  7. 7.
    Pouessel D, Gallet B, Bibeau F, Avancès C, Iborra F, Sénesse P, et al. Liver metastases in prostate carcinoma: clinical characteristics and outcome. BJU Int. 2007;99(4):807–11.Google Scholar
  8. 8.
    Droz J.-P., A. Fléchon C. Terret et al. Prostate cancer: management of advanced disease Centre Léon-Bérard, Department of Medical Oncology, Lyon, France. Eur Urol 2017.Google Scholar
  9. 9.
    Wang H, Li B, Zhang P, Yao Y, Chang J. Clinical characteristics and prognostic factors of prostate cancer with liver metastases. Tumour Biol. 2014;35(1):595–601.CrossRefPubMedGoogle Scholar
  10. 10.
    Bubendorf L, Schopfer A, Wagner U, et al. Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients. Hum Pathol. 2000;31(5):578–83.CrossRefPubMedGoogle Scholar
  11. 11.
    Lamothe F, Kovi J, Heshmat MY, Green EJ. Dissemination of prostatic carcinoma: an autopsy study. J Nat Med Assoc. 1986:1083–6.Google Scholar
  12. 12.
    Vinjamoori AH, Jagannathan JP, Shinagare AB, Taplin ME, Oh WK, van den Abbeele AD, et al. Atypical metastases from prostate cancer: 10-year experience at a single institution. AJR. 2012;199:367–72.CrossRefPubMedGoogle Scholar
  13. 13.
    Lin E, Garg K, Escott E et al. Practical differential diagnosis for CT and MRI. Thieme Medical Pub. 2008.Google Scholar
  14. 14.
    Namasivayam S, Martin DR, Saini S. Imaging of liver metastases: MRI. Cancer Imaging. 2007;7:2–9.  https://doi.org/10.1102/1470-7330.2007.0002.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Pascali C, Bogni A, Iwata R. 11C-methylation on 18C SepPakcartridge: a convenient way to produce [N-methyl-11C]choline. J Labelled Comp Radiopharm. 2000;49:195–203.CrossRefGoogle Scholar
  16. 16.
    Giovacchini G, Giovannini E, Leoncini R, Riondato M, Ciarmiello A. PET and PET/CT with radiolabeled choline in prostate cancer: a critical reappraisal of 20 years of clinical studies. Eur J Nucl Med Mol Imaging. 2017;44(10):1751–76.  https://doi.org/10.1007/s00259-017-3700-x.CrossRefPubMedGoogle Scholar
  17. 17.
    Goldstein J, Even-Sapir E, Ben-Haim S, Saad A, Spieler B, Davidson T, et al. Choline PET/CT change the Management of Prostate Cancer Patients with Biochemical Failure? Am J Clin Oncol. 2017;40(3):256–9.  https://doi.org/10.1097/COC.0000000000000139.
  18. 18.
    Ceci F, Herrmann K, Hadaschik B, Castellucci P, Fanti S. Therapy assessment in prostate cancer using choline and PSMA PET/CT. Eur J Nucl Med Mol Imaging. 2017;  https://doi.org/10.1007/s00259-017-3723-3.
  19. 19.
    García J.R., E. Franquet, N. Romera, M. Moragas, S. Jorcano y G. Moragas. Low diagnostic yield of the 11C-choline PET/CT in the detection of liver metastasis from prostate cancer. Rev Esp Med Nucl Imagen Mol 2014;33(1):56-57.Google Scholar
  20. 20.
    Kelly WK, Halabi S, Carducci MA, George DJ, Mahoney JF, Stadler WM, et al. Liver metastases (LM) to predict for short overall survival (OS) in metastatic castration-resistant prostate cancer (mCRPC) patients (pts). J ClinOncol. 2012;30(suppl; abstr 4655).Google Scholar
  21. 21.
    Zukotynski K, Kim C, Gerbaudo V, Hainer J, Taplin M, Kantoff P, et al. (18)F-FDG-PET/CT and (18)F-NaF-PET/CT in men with castrate-resistant prostate cancer. Am J Nucl Med Mol Imaging. 2014;5(1):72–82.Google Scholar
  22. 22.
    Watanabe H, Kanematsu M, Kondo H, Kako N, Yamamoto N, Yamada T, et al. Preoperative detection of prostate cancer: a comparison with 11C-choline PET, 18F-fluorodeoxyglucose PET, and MR imaging. J Magn Reson Imaging. 2010;31:1151–6.Google Scholar
  23. 23.
    Jadvar H, Desai B, Ji L, Conti PS, Dorff TB, Groshen SG, et al. Baseline 18F-FDG PET/CT parameters as imaging biomarkers of overall survival in castrate-resistant metastatic prostate cancer. J Nucl Med. 2013;54(8):1195–201.  https://doi.org/10.2967/jnumed.112.114116.
  24. 24.
    Minamimoto R, Uemura H, Sano F, Terao H, Nagashima Y, Yamanaka S, et al. The potential of FDG PET/CT for detecting prostate cancer in patients with an elevated serum PSA level. Ann Nucl Med. 2011;25:21–7.Google Scholar
  25. 25.
    Ost P, Bossi A, Decaestecker K, De Meerleer G, Giannarini G, Karnes RJ. Metastasis-directed therapy of regional and distant recurrences after curative treatment of prostate cancer: a systematic review of the literature. Eur Urol. 2015;67(5):852–63.CrossRefPubMedGoogle Scholar
  26. 26.
    Schulman C, Irani J, Aapro M. Improving the management of patients with prostate cancer receiving long-term androgen deprivation therapy. BJU Int. 2012;109:13–21.CrossRefPubMedGoogle Scholar
  27. 27.
    Loblaw DA, Walker-Dilks C, Winquist E, Hotte SJ. Systemic therapy in menwith metastatic castration-resistant prostate cancer: a systematic review. ClinOncol (R CollRadiol). 2013;25:406–30.Google Scholar
  28. 28.
    Parker C, Nilsson S, Heinrich D, et al. Alpha emitter Radium-223 and survival in metastatic prostate cancer. N Engl J Med. 2013;369:213–23.  https://doi.org/10.1056/NEJMoa12137.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  • Pietro Ghedini
    • 1
  • I. Bossert
    • 1
    • 2
  • L. Zanoni
    • 1
  • F. Ceci
    • 1
  • T. Graziani
    • 1
  • P. Castellucci
    • 1
  • V. Ambrosini
    • 1
  • F. Massari
    • 3
  • E. Nobili
    • 3
  • B. Melotti
    • 3
  • A. Musto
    • 4
  • S. Zoboli
    • 4
  • L. Antunovic
    • 5
  • M. Kirienko
    • 5
  • A. Chiti
    • 5
  • C. Mosconi
    • 6
  • A. Ardizzoni
    • 3
  • R. Golfieri
    • 6
  • S. Fanti
    • 1
  • C. Nanni
    • 1
  1. 1.Nuclear Medicine Unit, Medicina Nucleare MetropolitanaUniversity Hospital S.Orsola-MalpighiBolognaItaly
  2. 2.Nuclear Medicine ServiceIstituti Clinici Scientifici Maugeri SpA SB IRCSPaviaItaly
  3. 3.Oncology DepartmentUniversity Hospital S.Orsola-MalpighiBolognaItaly
  4. 4.Nuclear Medicine Department, Medicina Nucleare MetropolitanaMaggiore HospitalBolognaItaly
  5. 5.Nuclear Medicine DepartmentIRCCS HumanitasRozzanoItaly
  6. 6.RadiologyUniversity Hospital S.Orsola-MalpighiBolognaItaly

Personalised recommendations