Not All Glittering Bone Lesions Are Gold: A Case of Sclerotic Bone Lesions with Elevated ⁶⁸Ga PSMA and ^99mTc HDP Uptake with No Signs of Malignancy

Abstract

Gallium-68 prostate-specific membrane antigen positron emission tomography/computed tomography (⁶⁸Ga PSMA PET/CT) outperforms CT and bone scintigraphy in terms of diagnostic accuracy for the primary staging of prostate cancer and has become widely used. However, ⁶⁸Ga PSMA uptake is also encountered in nonprostatic tissue. We present a 63-year-old male with newly diagnosed high-risk prostate cancer who underwent bone scintigraphy with single-photon emission computed tomography/computed tomography (SPECT/CT), which showed inhomogeneous elevated uptake in sclerotic bone lesions in the pelvis. Likewise, ⁶⁸Ga PSMA PET/CT revealed inhomogeneous uptake in the same areas. Subsequent biopsy revealed hyperplastic bone marrow without signs of malignancy. The patient underwent radical prostatectomy, and the prostate-specific antigen level dropped to less than 0.1 ng/mL.

Keywords

⁶⁸Ga PSMA PET/CT - bone scan - prostate cancer - primary staging

Introduction

Prostate cancer is one of the most common malignancies in the Western world and frequently metastasizes to lymph nodes or bone; particularly bone metastases are the major cause of morbidity in advanced prostate cancer.[1] For primary staging of high-risk prostate cancer, gallium-68 prostate-specific membrane antigen positron emission tomography/computed tomography (⁶⁸Ga PSMA PET/CT) has proven to be a highly accurate diagnostic tool.[2]

Although ⁶⁸Ga PSMA—as the name implies—is relatively prostate tissue-specific, several cases have demonstrated elevated ⁶⁸Ga PSMA uptake in benign bone lesions.

Case History

A 63-year-old male was diagnosed with high-risk prostate cancer (prostate-specific antigen [PSA] 4.7 ng/mL, Gleason score 9 [4 + 5, International Society of Urological Pathology (ISUP) grade 5], stage T1c) and referred for a ^99mTc bone scan and CT of the thorax, abdomen, and pelvis. The bone scan revealed slightly elevated, inhomogeneous tracer uptake ([Fig. 1A], bone scan in posterior projection; [Fig. 1B], axial single-photon emission computed tomography [SPECT]) correlating with inhomogeneous sclerotic lesions of both iliac bones on the corresponding CT ([Fig. 1C]) and as shown in the fused SPECT/CT image ([Fig. 1D]). Bone metastases were suspected, but due to the rather unusual appearance, the patient was referred to ⁶⁸Ga PSMA PET/CT for the further evaluation of the disease stage.

Fig. 1 Whole body bone scan and single-photon emission computed tomography/computed tomography.

The maximal intensity projection in the posterior view of the ⁶⁸Ga PSMA-11 PET/CT ([Fig. 2A]) showed inhomogeneous low-to-moderate PSMA uptake (maximum standardized uptake value: 4.5–5.0) of both iliac bones, as shown in the axial PET image (arrows, [Fig. 2B]), corresponding to several small sclerotic lesions seen on the corresponding CT (arrows, [Fig. 2C]). The fused axial image is shown in [Fig. 2D]. In addition, the PSMA uptake pattern showed increased uptake along the iliac crest ([Fig. 2A]), which was not typical for bone metastases; for this reason, a bone biopsy was conducted to confirm or rule out bone metastases. CT-guided fine-needle and core-needle biopsies of the left ilium were conducted, and microscopic analysis revealed normal bone marrow with trilinear hyperplasia without any signs of malignancy. Immunohistochemistry analysis with the prostate-specific markers NKX3 and PSA was negative.

Fig. 2 Prostate-specific membrane antigen positron emission tomography/computed tomography.

The patient underwent curatively intended radical prostatectomy with dissection of seminal vesicles and pelvic lymph nodes. Final pathology revealed prostate cancer pT2c N0 M0, Gleason score 7 (4 + 3), ISUP grade 3, and a spontaneous decrease in the PSA level to less than 0.1 ng/mL following prostatectomy, supporting the diagnosis of benign changes in the pelvic bones.

Discussion

⁶⁸Ga PSMA PET/CT has proven to be a highly accurate diagnostic tool for staging newly diagnosed high-risk prostate cancer.[2] Despite the name prostate-specific membrane antigen, several studies have reported ⁶⁸Ga PSMA uptake in other types of cancer,[3] as well as several types of benign bone lesions, such as osteoid osteoma,[4] vertebral hemangioma,[5] myeloma,[6] fractures,[7] osteophytes[8] and Paget's disease.[9] Despite such findings, the specificity of ⁶⁸Ga PSMA PET/CT is very satisfactory and is often reported to be 93 to 98%.[2] [10] However, the present case emphasizes the need for biopsy when PSMA PET/CT is not entirely diagnostic of metastases to assign the correct treatment to the patient.

Conflict of Interest

None declared.

Note

The patient was scanned and treated at Aalborg University Hospital, Aalborg, Denmark.

Authors' Contributions

Authors are credited in the presented order of authorship. Morten Bentestuen was responsible for the completion of the present case report, gathered data, drafted manuscripts and created all figures. Helle Damgaard Zacho supervised the process. Maria Carlsen Elkjær and Helle Damgaard Zacho revised drafts and accepted the final product.

• References

• 1 Taitt HE. Global trends and prostate cancer: a review of incidence, detection, and mortality as influenced by race, ethnicity, and geographic location. Am J Men Health 2018; 12 (06) 1807-1823
• 2 Hofman MS, Lawrentschuk N, Francis RJ. et al; proPSMA Study Group Collaborators. Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study. Lancet 2020; 395 (10231): 1208-1216
• 3 Zacho HD, Pedersen SH, Petersen A, Petersen LJ. 68Ga-PSMA PET/CT uptake in the ureter caused by ligand expression in urothelial cancer. Clin Nucl Med 2020; 45 (01) e43-e45
• 4 Castello A, Lopci E. Incidental identification of osteoid osteoma by ⁶⁸Ga-PSMA PET/CT. Eur J Nucl Med Mol Imaging 2018; 45 (03) 509-510
• 5 Artigas C, Otte FX, Lemort M, van Velthoven R, Flamen P. Vertebral hemangioma mimicking bone metastasis in 68Ga-PSMA ligand PET/CT. Clin Nucl Med 2017; 42 (05) 368-370
• 6 Merrild EH, Baerentzen S, Bouchelouche K, Buus S. Vertebral myeloma mimicking prostatic carcinoma metastasis in 68Ga-PSMA PET/CT. Clin Nucl Med 2017; 42 (10) 790-792
• 7 Vamadevan S, Le K, Bui C, Mansberg R. Incidental PSMA uptake in an undisplaced fracture of a vertebral body. Clin Nucl Med 2017; 42 (06) 465-466
• 8 Jochumsen MR, Madsen MA, Gammelgaard L, Bouchelouche K. Lumbar osteophyte avid on 68Ga-prostate-specific membrane antigen PET/CT. Clin Nucl Med 2018; 43 (06) 456-457
• 9 Sasikumar A, Joy A, Nanabala R, Pillai MR, TA H. 68Ga-PSMA PET/CT false-positive tracer uptake in Paget disease. Clin Nucl Med 2016; 41 (10) e454-e455
• 10 Petersen LJ, Zacho HD. PSMA PET for primary lymph node staging of intermediate and high-risk prostate cancer: an expedited systematic review. Cancer Imaging 2020; 20 (01) 10

Publication History

Article published online:
20 December 2022