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Quantification of bone flare on 18F-NaF PET/CT in metastatic castration-resistant prostate cancer

Prostate Cancer and Prostatic Diseases volume 22, pages 324–330 (2019)Cite this article

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Abstract

Background

Bone flare has been observed on 99mTc-MDP bone scans of patients with metastatic castration-resistant prostate cancer (mCRPC). This exploratory study investigates bone flare in mCRPC patients receiving androgen receptor (AR) inhibitors using 18F-NaF PET/CT.

Methods

Twenty-nine mCRPC patients undergoing AR-inhibiting therapy (abiraterone, orteronel, enzalutamide) received NaF PET/CT scans at baseline, week 6, and week 12 of treatment. SUV metrics were extracted globally for each patient (SUV) and for each individual lesion (iSUV). Bone flare was defined as increasing SUV metrics or lesion number at week 6 followed by subsequent week 12 decrease. Differences in metrics across timepoints were compared using Wilcoxon tests. Cox proportional hazard regression was conducted between global metrics and progression-free survival (PFS).

Results

Total SUV was most sensitive for flare detection and was identified in 14/23 (61%) patients receiving CYP17A1-inhibitors (abiraterone, orteronel), and not identified in any of six patients receiving enzalutamide. The appearance of new lesions did not account for initial increases in SUV metrics. iSUV metrics followed patient-level trends: bone flare positive patients showed a median of 72% (range: 0–100%) of lesions with total iSUV flare. Increasing mean SUV at week 6 correlated with extended PFS (HR = 0.58, p = 0.02).

Conclusion

NaF PET bone flare was present on 61% of mCRPC patients in the first 6 weeks of treatment with CYP17A1-inhibitors. Characterization provided in this study suggests favorable PFS in patients showing bone flare. This characterization of NaF flare is important for guiding treatment assessment schedules to better distinguish between patients showing bone flare and those truly progressing, and should be performed for all emerging mCRPC treatments and imaging agents.

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Acknowledgements

We would like to thank the patients who volunteered their time, imaging technologists for data acquisition, and Christine Jaskowiak for her assistance. We would also like to thank the University of Wisconsin Carbone Cancer Center. This study was supported by the Prostate Cancer Foundation (PCF) through the PCF Creativity Award (Liu, Jeraj) and PCF Mazzone Challenge Award (Jeraj, Liu), and conducted within the Prostate Cancer Clinical Trials Consortium (PCCTC). Additional support provided by the United States Department of Defense Prostate Cancer Research Program (W81XWH-17-0020)

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Authors and Affiliations

  1. Department of Medical Physics, University of Wisconsin, Madison, WI, USA

    Amy J. Weisman, Stephanie A. Harmon, Timothy G. Perk, Glenn Liu & Robert Jeraj

  2. Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA

    Jens Eickhoff

  3. Molecular Imaging Program, National Cancer Institute, Bethesda, MD, USA

    Peter L. Choyke & Karen A. Kurdziel

  4. Genitourinary Malignancies Branch, National Cancer Institute, Bethesda, MD, USA

    William L. Dahut & Andrea B. Apolo

  5. Memorial Sloan Kettering Cancer Center, New York, NY, USA

    John L. Humm, Steven M. Larson & Michael J. Morris

  6. Department of Radiology, University of Wisconsin, Madison, WI, USA

    Scott B. Perlman

  7. Department of Medicine, University of Wisconsin, Madison, WI, USA

    Glenn Liu

  8. Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia

    Robert Jeraj

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  1. Amy J. Weisman
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  2. Stephanie A. Harmon
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  13. Glenn Liu
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  14. Robert Jeraj
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Corresponding authors

Correspondence to Amy J. Weisman or Robert Jeraj.

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Conflict of interest

Funding from this work received from the Prostate Cancer Foundation. RJ and GL are cofounders of AIQ Solutions. The remaining authors declare that they have no conflict of interest.

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Weisman, A.J., Harmon, S.A., Perk, T.G. et al. Quantification of bone flare on 18F-NaF PET/CT in metastatic castration-resistant prostate cancer. Prostate Cancer Prostatic Dis 22, 324–330 (2019). https://doi.org/10.1038/s41391-018-0110-5

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