TY - JOUR
T1 - PSMA-avid rib lesions in prostate cancer patients
T2 - differentiating false positives from metastatic disease
AU - Woo, Sungmin
AU - Becker, Anton S.
AU - Leithner, Doris
AU - Charbel, Charlotte
AU - Mayerhoefer, Marius E.
AU - Friedman, Kent P.
AU - Tong, Angela
AU - Murina, Sofya
AU - Siskin, Matthew
AU - Taneja, Samir S.
AU - Zelefsky, Michael J.
AU - Wise, David R.
AU - Vargas, Hebert A.
N1 - Publisher Copyright:
© The Author(s), under exclusive licence to European Society of Radiology 2025.
PY - 2025
Y1 - 2025
N2 - Objectives: Prostate-specific membrane antigen (PSMA)-PET/CT has become integral to management of prostate cancer; however, PSMA-avid rib lesions pose a diagnostic challenge. This study investigated clinicopathological and imaging findings that predict metastatic etiology of PSMA-avid rib lesions. Materials and methods: Consecutive patients with prostate cancer that underwent PET/CT with [18F]F-DCFPyL in 2021–2023 for newly diagnosed intermediate-/high-risk prostate cancer or recurrent/metastatic disease and had PSMA-avid rib lesions were included. Imaging findings assessed were: lesion number, PSMA expression (maximum standard uptake value (SUVmax), miPSMA score), CT features (sclerotic, lucent, fracture, no correlate), other sites of metastases, and primary tumor findings. A composite reference standard for rib lesion etiology (metastatic vs non-metastatic) based on histopathology, serial imaging, and clinical assessment was used. Results: One hundred and seventy-five men (median 71 years, IQR 65–77) with PSMA-avid rib lesions were included; 47/175 (26.9%) had rib metastases. Only 1/47 (2.1%) of these patients had isolated rib metastasis without PSMA-avid metastases in other bones, nodes, or visceral organs; the other 46/47 (97.9%) patients with rib metastases also had other sites of PSMA-avid disease. Patients with rib metastases were older, had higher prostate-specific antigen levels, and higher-grade tumors (p < 0.01). Metastatic rib lesions had higher uptake (SUVmax, miPSMA), more commonly involved multiple ribs, and were more often sclerotic (p < 0.01); lucency/fractures were only seen in benign lesions. Conclusion: Several imaging and clinicopathological factors differed between PSMA-avid metastatic and benign lesions. Isolated rib lesions without other sites of metastasis are almost always benign. Careful assessment of CT features can help diagnose benign lesions. Key Points: Question While prostate-specific membrane antigen (PSMA)-PET/CT has become integral to the management of prostate cancer, PSMA-avid rib lesions pose a diagnostic challenge. Findings Approximately a quarter of patients who had PSMA-avid rib lesions were metastatic. However, only 2.1% of them had isolated rib metastasis (without PSMA-avid metastases elsewhere). Clinical relevance Isolated PSMA-avid rib lesions are almost always benign when there is no evidence of metastatic disease elsewhere. Scrutinizing CT features can help diagnose benign PSMA-avid lesions with greater certainty.
AB - Objectives: Prostate-specific membrane antigen (PSMA)-PET/CT has become integral to management of prostate cancer; however, PSMA-avid rib lesions pose a diagnostic challenge. This study investigated clinicopathological and imaging findings that predict metastatic etiology of PSMA-avid rib lesions. Materials and methods: Consecutive patients with prostate cancer that underwent PET/CT with [18F]F-DCFPyL in 2021–2023 for newly diagnosed intermediate-/high-risk prostate cancer or recurrent/metastatic disease and had PSMA-avid rib lesions were included. Imaging findings assessed were: lesion number, PSMA expression (maximum standard uptake value (SUVmax), miPSMA score), CT features (sclerotic, lucent, fracture, no correlate), other sites of metastases, and primary tumor findings. A composite reference standard for rib lesion etiology (metastatic vs non-metastatic) based on histopathology, serial imaging, and clinical assessment was used. Results: One hundred and seventy-five men (median 71 years, IQR 65–77) with PSMA-avid rib lesions were included; 47/175 (26.9%) had rib metastases. Only 1/47 (2.1%) of these patients had isolated rib metastasis without PSMA-avid metastases in other bones, nodes, or visceral organs; the other 46/47 (97.9%) patients with rib metastases also had other sites of PSMA-avid disease. Patients with rib metastases were older, had higher prostate-specific antigen levels, and higher-grade tumors (p < 0.01). Metastatic rib lesions had higher uptake (SUVmax, miPSMA), more commonly involved multiple ribs, and were more often sclerotic (p < 0.01); lucency/fractures were only seen in benign lesions. Conclusion: Several imaging and clinicopathological factors differed between PSMA-avid metastatic and benign lesions. Isolated rib lesions without other sites of metastasis are almost always benign. Careful assessment of CT features can help diagnose benign lesions. Key Points: Question While prostate-specific membrane antigen (PSMA)-PET/CT has become integral to the management of prostate cancer, PSMA-avid rib lesions pose a diagnostic challenge. Findings Approximately a quarter of patients who had PSMA-avid rib lesions were metastatic. However, only 2.1% of them had isolated rib metastasis (without PSMA-avid metastases elsewhere). Clinical relevance Isolated PSMA-avid rib lesions are almost always benign when there is no evidence of metastatic disease elsewhere. Scrutinizing CT features can help diagnose benign PSMA-avid lesions with greater certainty.
KW - Neoplasm metastasis
KW - Positron-emission tomography
KW - Prostate-specific membrane antigen
KW - Prostatic neoplasms
KW - Ribs
UR - http://www.scopus.com/inward/record.url?scp=105000827188&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=105000827188&partnerID=8YFLogxK
U2 - 10.1007/s00330-025-11514-3
DO - 10.1007/s00330-025-11514-3
M3 - Article
AN - SCOPUS:105000827188
SN - 0938-7994
JO - European Radiology
JF - European Radiology
M1 - 31
ER -