Introduction
Materials and methods
Study population
Case selection and imaging analysis
Imaging protocols and reconstruction
Statistical analysis
Results
Confirmed prostate cancer metastases
No | Age | Indication | PSA | Site | Primary SUV | SUV | miPSMA Expression Score | Findings | Clinical Rationale | Outcome |
---|---|---|---|---|---|---|---|---|---|---|
1 | 74 | Biochemical persistence post RP | 3.9 | Lung | N/A | 7.6 | 2 | Solitary LLL nodule 13 mm. No evidence of PCa recurrence elsewhere. Multiple pleural plaques | Morphological appearances suggestive of lung adenocarcinoma lung in increased risk patient without PCa recurrence elsewhere | Biopsy |
2 | 66 | BF post RP | 0.53 | Lung | N/A | 11.6 | 2 | Solitary 8 mm RUL lesion, no evidence of PCa recurrence elsewhere | In context of no other sites of recurrence, primary lung cancer should be excluded | Wedge Resection |
3 | 70 | BF post RP | 0.3 | Lung | N/A | 22.0 | 3 | High PSMA expression 10 mm LUL nodule. No prostate bed recurrence, equivocal expression in 4 mm left mesorectal node | Equivocal disease elsewhere. Primary lung cancer should be excluded | Resolution of lesion on CT follow up on hormonal therapy |
4 | 71 | Initial Staging | 11.6 | Lung | 8.5 | 11.5 | 2 | 21 × 12 mm RUL lobulated solitary nodule in a patient with pulmonary emphysema | No evidence of recurrence elsewhere and significant smoking related lung disease. Primary lung cancer should be excluded | Resection |
5 | 77 | Initial Staging | 2.6 | Lung Bone Node | 4.0 | < 1.0 6.2 4.0 | 0 | Multiple pulmonary nodules with no PSMA expression, but primary low expression. Low expression enlarged pelvic nodes and sclerotic bone lesions | DDx given as dedifferentiated neuro-endocrine tumour of prostate or metastases from bladder TCC | Lung nodules reduced with Docetaxel and Goserelin |
6 | 60 | BF post RP | 3.9 | Lung | N/A | 1.0 | 0 | Multiple new and enlarged pulmonary nodules with low expression, largest 12 × 14 mm RLL apical segment | DDx metastatic PCa versus other malignancy | VATS wedge resection |
7 | 66 | BF post XRT | 24 | Node | N/A | 14.1 | 3 | High PSMA expression within left para aortic and left pelvic nodes. * | Recent diagnosis of DLBCL confined to mediastinum. Considered most likely PCa but DLBCL should be excluded | Left para-aortic node excision |
8 | 66 | Metastatic PCa on Zoladex, new right pelvic pain | 0.4 | Bone | 45.6 | 5.3 | 1 | Known multiple PCa bone metastases. New 73 mm expansile lytic right iliac lesion with predominant soft tissue mass, low PSMA expression | Dissimilar appearance to other bony metastases and previous pelvic RT for seminoma, exclude NPCaT | Bone biopsy |
Non-prostate cancer tumours
Age | Indication | Site | Primary SUVmax | SUVmax | miPSMA Expression Score | Findings | Outcome | Pathology | Malignant Potential | Additional PSMA Findings | |
---|---|---|---|---|---|---|---|---|---|---|---|
1 | 77 | BF | Lung | N/A | 3.8 | 1 | 29 mm LLL nodule | Biopsy | Primary lung adenocarcinoma | High | Uptake in seminal vesicle and inguinal node |
2 | 79 | BF | Lung | 29.2 | 4.8 | 1 | RLL mass | Biopsy | Non-small cell lung cancer | High | Nil |
3 | 73 | Post treatment | Kidney | N/A | < 1 | 0 | 34 mm right renal lesion | Biopsy | Renal cell carcinoma | High | Nil |
4 | 95 | Initial Staging | Kidney | 72 | 19.9 | 3 | 78 mm left renal lesion | Clinical | Renal cell carcinoma | High | Nil |
5 | 71 | BF | Breast | N/A | 2.8 | 1 | 10 mm left upper outer lesion | Biopsy | Invasive carcinoma of no special type | High | Nil |
6 | 72 | Initial Staging | Pituitary | 17.8 | 1.8 | 1 | Pituitary enlargement | Clinical | Subsequent MRI – pituitary macroadenoma | Low | Uptake within prostate and left superior pubic ramus |
7 | 66 | BF | Colon | 52.7 | 4.4 | 1 | Distal transverse colon lesion | Biopsy | Colonic adenocarcinoma | High | Uptake in pre-sacral node |
8 | 81 | Initial Staging | Colon | 55.6 | 3.9 | 1 | Ascending colon lesion | Biopsy | Colonic adenocarcinoma and terminal ileum neuroendocrine tumour | High | Uptake in prostate gland |
9 | 63 | BF | Colon | N/A | < 1 | 0 | 5 cm tubular structure in right iliac fossa | Clinical | Appendix mucocele | Low | Nil |
10 | 64 | BF | Brain | N/A | < 1 | 0 | Right posterior temporal lesion | Clinical | Subsequent MRI – Meningioma | Low | Nil |
11 | 64 | Initial Staging | Pancreas | 6 | 4.8 | 1 | Dilated pancreatic and bile ducts | Biopsy | Poorly differentiated pancreatic adenocarcinoma | High | Nil |
12 | 59 | Initial Staging | Brain | 0 | 4.5 | 1 | Intracranial lesion | Clinical | Subsequent MRI – Glioblastoma | High | Nil |
13 | 77 | Initial Staging | Lung | 52.7 | 2.5 | 1 | 23 mm RLL nodule | Biopsy | Primary lung adenocarcinoma | High | Uptake in prostate, seminal vesicles, pelvic nodes and bone |
14 | 73 | Initial Staging | Kidney | 134 | 4 | 1 | Left upper pole lesion | Clinical | Not investigated due to pre-existing widespread metastatic malignancy | High | Widespread uptake |
15 | 79 | Initial Staging | Lymph Node | 98.1 | 3.5 | 1 | 24 × 14 mm circumscribed soft tissue lesion posterior to D3 | Biopsy | Follicular Lymphoma (cervical node) | High | Uptake in prostate gland |
16 | 70 | BF | Lung | 0 | 4.7 | 1 | 15 mm left upper lobe nodule | Clinical | Not amenable to biopsy. Likely lung cancer | High | Nil |
17 | 70 | BF | Kidney | 17.9 | 10 | 2 | Left renal mass | Clinical | Characteristic for renal cell carcinoma | High | Uptake in pelvic nodes, para-aortic nodes and bone |
Indeterminate lesions
No | Age | Indication | Site | Primary SUV | SUV | miPSMA Expression Score | Findings | Clinical Rationale | Outcome | |
---|---|---|---|---|---|---|---|---|---|---|
LIKELY MALIGNANT | 1 | 80 | Re-Staging | Node | 29.2 | 1.9 | 1 | Low PSMA expression in left pelvic node. Uptake in left pelvic node. | Known metastatic PCa with bony metastases but no other nodal disease and expression much lower than bone metastases. | Further investigation not pursued due to lesions elsewhere and treated as PCa nodal metastasis |
2 | 69 | Initial Staging | Node | 19.2 | 2.4 | 1 | Uptake in prostate and multiple bilateral prominent iliac nodes up to 12mm, much lower expression than primary. | No confirmation. | Commenced on ADT. | |
3 | 76 | BCR post RP | Lung | N/A | 1.7 | 1 | 11mm ground glass nodule within LUL. | Likely synchronous primary lung Ca. | Follow up CT in 3 months advised. No follow up at STV. | |
4 | 95 | Initial Staging | Lung | N/A | 2.1 | 1 | Uptake in prostate gland and 19mm spiculated lung nodule in RUL. | Likely synchronous primary lung Ca. | No follow up given age and comorbidities. | |
5 | 72 | BF post RP | Lung | 49.8 | 4.2 | 1 | Irregular 14mm pulmonary lesion RUL. Uptake in pelvic nodes. | Likely primary lung adenocarcinoma | No follow up. | |
6 | 83 | Re-Staging | Lung | 21.4 | 1.3 | 1 | Uptake in prostate gland and 10mm RLL ground glass pulmonary nodule. | Uncertain significance, possible lung primary. | Stable on follow up CT (4 months). Ongoing follow up. | |
7 | 65 | Initial Staging | Skin | N/A | 2.1 | 1 | 10mm right thigh lesion. | No evidence of primary or metastatic prostate cancer | No follow up as widespread metastases from separate neuroendocrine tumour | |
8 | 75 | Re-Staging | Bladder | 42.9 | N/A* | N/A* | Widespread uptake involving prostate, nodes and right VUJ lesion. | Primary bladder tumour. | No follow up, patient resident abroad and left New Zealand | |
9 | 81 | Initial Staging | Lung | 26.1 | 2.7 | 1 | Uptake in prostate, pelvic nodes and low PSMA expression in 11mm nodule within RUL | Likely primary lung adenocarcinoma. | No follow up given comorbidities and age. | |
10 | 73 | Initial Staging | Node | 26.1 | 2.1 | 1 | Uptake in prostate, pelvic nodes and low PSMA expression in 14mm mesenteric node | High expression in prostate and pelvic node considered typical for prostate cancer. Mesenteric node indeterminate. | Commenced on ADT with pelvic Radiotherapy. Awaiting further follow-up. | |
LIKELY BENIGN | 1 | 79 | BF post RP | Lung | 12.1 | 2.6 | 1 | Uptake in prostate gland and low PSMA expression in LUL ground glass change | Likely inflammatory. | No follow up. |
2 | 72 | Initial Staging | Lung | 17 | 4.9 | 1 | Uptake in prostate gland and low PSMA expression in LUL ground glass change | Likely inflammatory. | No follow up. | |
3 | 84 | BF post RP | Liver | N/A | 13.4 | 3 | High PSMA expression within segment 4 of the liver. | Image noise versus liver metastasis, not solid organ disease elsewhere | Not present on follow up PSMA with rising PSA. Most likely benign or artefact. | |
4 | 77 | BF post RP | Lung | N/A | 2.2 | 1 | Low PSMA expression in 12mm RUL lung nodule[1] | Two sigmoid lesions FDG avid ?metastasis from bowel/prostate or benign lesion | Follow up CT 2 years later showed no significant change in lesion. | |
5 | 69 | BF post RP | Lung | N/A | 1.6 | 1 | Minimal PSMA expression in 9mm irregular pulmonary nodule | Solitary pelvic node recurrence. Indeterminate lung nodule. | No change on surveillance imaging for over 2 years. | |
6 | 76 | BF post RP | Kidney | N/A | <1 | 0 | 30mm heterogeneous right retroperitoneal lesion abutting inferior pole of right kidney | Likely benign cyst or lymphatic lesion, exclude sarcoma. | Non-enhancing on dedicated triple phase CT and unchanged over 13 months. | |
7 | 79 | BF post RP | Bone | N/A | <1 | 0 | Low PSMA expression in sclerotic left temporal bone lesion. | Likely benign lesion. | No further imaging. Remained asymptomatic. | |
8 | 69 | BF post RP | Sinus | N/A | 7.5 | 2 | Intermediate PSMA expression in left maxillary sinus mass. | Likely inflammatory, exclude tumour. | Follow up with ENT – CT/MRI demonstrating no suspicious lesion. Changes resolved on imaging 3 years later | |
9 | 70 | Initial Staging | Bone | N/A | <1 | 0 | Sclerotic right sacral alar lesion with no PSMA expression, significant expression in primary. | Indeterminate lesion, possibly benign. | FDG PET/CT 2 weeks later demonstrated no avidity. Follow up over 18 months no change | |
10 | 56 | BF post RP | Colon | N/A | <1 | 0 | No PSMA expression within sigmoid colon. | Clinical and radiological evidence of diverticulitis. | Resolved. Subsequent PSMA PET/CT no uptake. | |
11 | 83 | BF post RP | Lung | N/A | <1 | 0 | No PSMA expression within the lung. | Likely rounded atelectasis. | Resolved on subsequent CT. | |
12 | 74 | BF post RP | Larynx | N/A | <1 | 0 | Uptake in seminal vesicle and solid nodule within right false vocal cord. | Likely right laryngocele. | No progression with clinical surveillance. | |
13 | 67 | BF post RP | Spleen | N/A | 13 | 3 | Pelvic nodal recurrence with low PSMA expression. 7mm hypodense splenic lesion | Indeterminate splenic lesion | Not suitable and patient reluctant for active treatment. Patient remains well over 4 years of clinic follow up. | |
14 | 61 | BF post RP | Retro-peritoneal | N/A | <1 | 0 | Thin walled cystic retro-peritoneal lesion. | Most likely benign. | Patient underwent salvage radiotherapy. No specific follow up of retroperitoneal lesion. | |
15 | 63 | Initial Staging | Lung | 10.8 | 4.2 | 1 | Uptake in prostate gland and 18mm pleural based nodule | Likely benign. | Resolved on follow up CT 3 months later. | |
16 | 50 | Initial Staging | Skin | N/A | 3.2 | 1 | Uptake in prostate gland and left paraspinal subcutaneous nodule with low PSMA expression. | Likely benign. | No change on follow up PSMA. No specific comment on follow up regarding skin lesion. | |
17 | 75 | BF post RP | Lung | N/A | < 1 | 0 | No PSMA expression in a patchy opacity in LUL. | Likely inflammatory changes. | Follow up CT in 6 weeks advised. No follow up at STV. | |
18 | 73 | BF post RP | Thyroid | N/A | 1.7 | 1 | Indeterminate heterogeneous 24mm left thyroid nodule | Likely benign nodule. | No follow up. | |
19 | 62 | Initial Staging | Scrotum | 15.1 | 5.2 | 2 | Bilateral scrotal extra-testicular nodules | ? Epididymal metastases but no extra-prostatic disease elsewhere | Nodules not investigated. Patient proceeded to RP. BF 4 years later with repeat PSMA. No interval changes in scrotal nodules, considered benign |
Benign lesions
No | Age | Indication | Site | Primary SUV | SUV | miPSMA Expression Score | Findings | Clinical Rationale | Outcome |
---|---|---|---|---|---|---|---|---|---|
1 | 65 | Initial Staging | Lung | 8.9 | 1.6 | 1 | Uptake in prostate gland and 22 mm lesions within LUL | Suspected bronchogenic malignancy | Biopsy proven granuloma. Reduced in size on follow up imaging |
2 | 72 | BF post RP | Lung | 25.2 | 1.3 | 0 | Uptake in pelvic nodes and several pulmonary nodules (most significant 16 mm in RLL) | Suspected benign lesions given low PSMA expression | Wedge resection of RLL lesion confirming Hamartoma |
3 | 77 | BF post RP | Skin | 6.5 | 4.5 | 1 | Uptake in abdominal nodes and low PSMA expression in subcutaneous nodules (3 mm and 8 mm) | Direct visualization suggested | Biopsy proven angiolipoma |
4 | 72 | BF post RP | Skin | N/A | 3.1 | 1 | Low PSMA expression in skin lesion lower right lateral abdomen | Direct visualization suggested | Biopsy performed with non-specific findings, no malignancy |
5 | 65 | BF post RP | Skin | N/A | 3.0 | 1 | 18 mm subcutaneous right paraspinal lesion | Biopsy suggested | Biopsy proven hemangioma |
6 | 68 | Initial Staging | Breast | 58.3 | 2.8 | 1 | Low PSMA expression in left breast | Suspected gynaecomastia | Mammogram and biopsy performed confirming gynaecomastia |
7 | 65 | BCR post RP | Skin | N/A | 1.7 | 1 | Uptake in pelvic nodes and 28 mm rounded lesion deep to skin in right lower back | Probable cyst | Direct visualisation of lesions confirmed sebaceous cyst |
8 | 61 | BF post RP | Thyroid | N/A | 2.7 | 1 | Multinodular thyroid enlargement causing tracheal narrowing | Probable benign multinodular goitre | Ultrasound confirmation of benign features |
9 | 66 | BF post RT | Thyroid | 5.8 | 3.2 | 1 | Indeterminate heterogeneous left thyroid nodule with calcifications | Ultrasound ± FNA suggested | Biopsy proven benign thyroid nodule |
10 | 57 | BF post RP | Thyroid | N/A | 2.6 | 1 | 38 × 28 mm ovoid homogeneous mass in lower pole of left thyroid lobe | Ultrasound ± FNA suggested | Biopsy proven benign thyroid nodule |
11 | 69 | BF post RP | Thyroid | 5.5 | < 1 | 0 | No PSMA expression in a 40 mm nodule within the thyroid isthmus | Ultrasound suggested | Ultrasound confirmation of benign features |
12 | 66 | BF post RT | Thyroid | 3.5 | 4.6 | 1 | Indeterminate heterogeneous left thyroid nodule with calcifications | Ultrasound ± FNA suggested | Biopsy proven benign thyroid nodule |
13 | 70 | BF post RP | Thyroid | N/A | 2.3 | 1 | 25 mm heterogeneous density nodule in right thyroid with calcifications | Ultrasound suggested | Ultrasound confirmation of benign features |
14 | 58 | BF post RP | Scrotum | N/A | 7.8 | 2 | Unilateral right scrotal extra-testicular nodule with PSMA expression | ? Epididymal metastases but no recurrence elsewhere | Orchidectomy pre-salvage, histology showed granulomatous epididymitis |