Prostate cancer staging (PSMA PET-CT)

Presentation

Elevated PSA of 14 ng/dL. Abnormal digital rectal exam (DRE). US guided biopsy with 12/12 cores positive for adenocarcinoma.

Patient Data

Age: 60 years
Gender: Male
Nuclear medicine

F-18 PSMA PET-CT. MIP demonstrates a large area of abnormal intense, heterogenous radiotracer uptake in the deep pelvis, just below the bladder, corresponding to the region of the prostate gland. There is also a single small intense focus of radiotracer avidity just posterior to the physiologic activity in the left ureter and a faint focus of radiotracer avidity in the low left pelvis.

Axial fused PET-CT confirms the large area of intense heterogenous radiotracer in the prostate consistent with known, biopsy proven multifocal primary disease. The punctate intense activity posterior to the left ureter corresponds to a left iliac junctional lymph node. The faint focus of radiotracer in the low left pelvis corresponds to ischium.

CT shows a small sclerotic lesion in the ischium at site of PSMA avidity and the avid left iliac junctional lymph node to be 4 mm in size (short axis).

Case Discussion

PSMA PET-CT is indicated for staging in individuals with a new diagnosis of unfavorable intermediate risk (Gleason 4+3=7) or higher prostate cancer in order to assess extent of disease spread and help guide therapy.

This case demonstrates the value of the exam in such cases, as it identifies likely nodal spread of disease in a single 4-mm pelvic lymph node as well as a solitary site of biopsy proven bone metastasis.

The intense activity in the kidneys is physiological as is the moderate activity in the salivary glands, liver and spleen. Excreted radiotracer is present in the ureters, bladder and bowels.

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