Equivocal bone lesions on PSMA PET/CT: systematic review and meta-analysis on their prevalence and malignancy rate

Sungmin Woo, Daniel Freedman, Anton S. Becker, Doris Leithner, Marius E. Mayerhoefer, Kent P. Friedman, Yuki Arita, Sangwon Han, Irene A. Burger, Samir S. Taneja, David R. Wise, Michael J. Zelefsky, Hebert A. Vargas

Research output: Contribution to journalReview articlepeer-review


Purpose: Prostate-specific membrane antigen (PSMA) PET/CT has an established reliable diagnostic performance for detecting metastases in prostate cancer. However, there are increasing instances of scans demonstrating equivocal bone lesions, with non-specific uptake and without a definite benign or malignant CT correlate. To date, the prevalence, malignancy rate, and relationship with radioligand type ([18F] PSMA-1007 vs. others ([68Ga]Ga-PSMA-11 and [18F] DCFPyL) for these equivocal lesions have not been extensively established. Methods: A systematic review and meta-analysis was conducted on equivocal bone lesions. Pubmed and EMBASE were searched up to December 11, 2023. Quality of the studies was evaluated using QUADAS-2. The following proportions were pooled using random-effects model: (1) prevalence of equivocal bone lesions (i.e., number of patients with one or more equivocal bone lesions/number of patients with PSMA PET/CT) and (2) their malignancy rates (i.e., number of metastases/number of equivocal bone lesions). Subgroup analyses based on radioligand type, clinical setting, and definition of equivocal bone lesion were performed. Results: Twenty-five studies (4484 patients) were included. Pooled prevalence of equivocal bone lesions was 20% (95%CI, 12–31%). [18F]PSMA-1007 was associated with a greater prevalence of equivocal lesions compared with other radioligands: 36% (95%CI 26–48%) vs. 8% (95%CI, 4–14%), respectively, p < 0.01. Pooled malignancy rate of equivocal bone lesions was 14% (95%CI, 7–25%). [18F]PSMA-1007 was associated with a lower malignancy rate compared to other radioligands: 8% (95%CI, 3–19%) vs. 29% (95%CI, 17–44%), respectively, p = 0.01. There were no signficant difference in prevalence or malignancy rate between subgroups stratified to clinical setting or definition of equivocal bone lesions (p = 0.32–0.60). Conclusions: Equivocal bone lesions are often encountered on PSMA PET/CT but exihibit a low malignancy rate. Compared to other radioligands, [18F]PSMA-1007 requires special attention as it is associated with a higher frequency and lower rate of metastasis.

Original languageEnglish (US)
JournalClinical and Translational Imaging
StateAccepted/In press - 2024


  • Equivocal bone lesion
  • Positron emission tomography
  • Prostate cancer
  • Prostate specific membrane antigen
  • Unspecific bone uptake
  • [F]PSMA-1007

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging


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