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Tracer uptake in mediastinal and paraaortal thoracic lymph nodes as a potential pitfall in image interpretation of PSMA ligand PET/CT

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Abstract

Purpose

Since the introduction of 68Ga-PSMA-11 PET/CT for imaging prostate cancer (PC) we have frequently observed mediastinal lymph nodes (LN) showing tracer uptake despite being classified as benign. The aim of this evaluation was to further analyze such LN.

Methods

Two patient groups with biphasic 68Ga-PSMA-11 PET/CT at 1 h and 3 h p.i. were included in this retrospective evaluation. Group A (n = 38) included patients without LN metastases, and group B (n = 43) patients with LN metastases of PC. SUV of mediastinal/paraaortal LN of group A (n = 100) were compared to SUV of LN metastases of group B (n = 91). Additionally, 22 randomly selected mediastinal and paraaortal LN of patients without PC were immunohistochemically (IHC) analyzed for PSMA expression.

Results

In group A, 7/38 patients (18.4%) presented with at least one PSMA-positive mediastinal LN at 1 h p.i. and 3/38 (7.9%) positive LN at 3 h p.i. with a SUVmax of 2.3 ± 0.7 at 1 h p.i. (2.0 ± 0.7 at 3 h p.i.). A total of 11 PSMA-positive mediastinal/paraaortal LN were detected in nine patients considering both imaging timing points. SUVmax of LN-metastases was 12.5 ± 13.2 at 1 h p.i. (15.8 ± 17.0 at 3 h p.i.). SUVmax increased clearly (> 10%) between 1 h and 3 h p.i. in 76.9% of the LN metastases, and decreased significantly in 72.7% of the mediastinal/paraaortal LN. By IHC, PSMA-expression was observed in intranodal vascular endothelia of all investigated LN groups and to differing degrees within germinal centers of 15/22 of them (68.1%). Expression was stronger in mediastinal nodes (p = 0.038) and when follicular hyperplasia was present (p = 0.050).

Conclusion

PSMA-positive mediastinal/paraaortal benign LN were visible in a notable proportion of patients. PSMA-positivity on the histopathological level was associated with the activation state of the LN. However, in contrast to LN metastases of PC, they presented with significantly lower uptake, which, in addition, usually decreased over time.

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Acknowledgements

A large number of people helped to plan, investigate, and analyze the patients in past years. Amongst them are (in alphabetic order): Heidrun Adam, Stephanie Biedenstein, Renate Brück, Elena Dahlke, Larissa Engel, Tanja Gerwert, Prof. Frederik Giesel, Daniela Johna, Dr. Christian Kleist, Dr. Susanne Krämer, Dr. Clemens Kratochwil, Kirsten Kunze, Viktoria Reiswich, Franziska Seybold-Epting, Peter Seybold-Epting, Fabian Spohn, and Natalia Zimmermann.

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Authors and Affiliations

  1. Department of Nuclear Medicine, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany

    Ali Afshar-Oromieh, Lars Peter Sattler, Walter Mier & Uwe Haberkorn

  2. Department of Nuclear Medicine, Bern University Hospital (Inselspital), Bern, Switzerland

    Ali Afshar-Oromieh & Uwe Haberkorn

  3. Institute of Pathology, Technical University of Munich, Munich, Germany

    Katja Steiger & Wilko Weichert

  4. Department of Biostatistics, German Cancer Research Center, Heidelberg, Germany

    Tim Holland-Letz

  5. Department of Nuclear Medicine, Hospital Israelita Albert-Einstein, São Paulo, Brazil

    Marcelo Livorsi da Cunha

  6. Division of Radiopharmaceutical Chemistry, German Cancer Research Center, Heidelberg, Germany

    Oliver Neels & Klaus Kopka

  7. German Cancer Consortium (DKTK), Heidelberg, Germany

    Oliver Neels & Klaus Kopka

  8. German Cancer Consortium (DKTK), Munich, Germany

    Wilko Weichert

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  1. Ali Afshar-Oromieh
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Correspondence to Ali Afshar-Oromieh.

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Ethical approval

All patients published in this manuscript signed a written informed consent form for the purpose of anonymized evaluation and publication of their data. All reported investigations were conducted in accordance with the Helsinki Declaration and with our national regulations (German Medicinal Products Act, AMG §13 2b). This evaluation was approved by the ethics committee of the University of Heidelberg (S-321-2012).

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All authors declare that they have no conflict of interest.

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Afshar-Oromieh, A., Sattler, L.P., Steiger, K. et al. Tracer uptake in mediastinal and paraaortal thoracic lymph nodes as a potential pitfall in image interpretation of PSMA ligand PET/CT. Eur J Nucl Med Mol Imaging 45, 1179–1187 (2018). https://doi.org/10.1007/s00259-018-3965-8

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  • DOI: https://doi.org/10.1007/s00259-018-3965-8

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