Influence of PSA, PSA velocity and PSA doubling time on contrast-enhanced 18F-choline PET/CT detection rate in patients with rising PSA after radical prostatectomy

  • Orazio Schillaci
  • Ferdinando CalabriaEmail author
  • Mario Tavolozza
  • Cristiana Ragano Caracciolo
  • Enrico Finazzi Agrò
  • Roberto Miano
  • Antonio Orlacchio
  • Roberta Danieli
  • Giovanni Simonetti
Original Article



To evaluate the accuracy of contrast-enhanced 18F-choline PET/CT in restaging patients with prostate cancer after radical prostatectomy in relation to PSA, PSA velocity (PSAve) and PSA doubling time (PSAdt).


PET/CT was performed in 49 patients (age range 58–87 years) with rising PSA (mean 4.13 ng/ml) who were divided in four groups according to PSA level: ≤1 ng/ml, 1 to ≤2 ng/ml, 2 to ≤4 ng/ml, and >4 ng/ml. PSAve and PSAdt were measured. PET and CT scans were interpreted separately and then together.


PET/CT diagnosed relapse in 33 of the 49 patients (67%). The detection rates were 20%, 55%, 80% and 87% in the PSA groups ≤1, 1 to ≤2, 2 to ≤4 and >4 ng/ml, respectively. PET/CT was positive in 7 of 18 patients (38.9%) with a PSA ≤2 ng/ml, and in 26 of 31 (83.9%) with a PSA >2 ng/ml. PET/CT was positive in 7 of 25 patients (84%) with PSAdt ≤6 months, and in 12 of 24 patients (50%) with PSAdt >6 months, and was positive in 26 of 30 patients (86%) with a PSAve >2 ng/ml per year, and in 7 of 19 patients (36.8%) with PSAve ≤2 ng/ml per year. PET alone was positive in 31 of 49 patients (63.3%), and of these 31 patients, CT was negative in 14 but diagnosed bone lesions in 2 patients in whom PET alone was negative. CT with the administration of intravenous contrast medium did not provide any further information.


Detection rate of 18F-choline imaging is closely related to PSA and PSA kinetics. In particular, 18F-choline PET/CT is recommended in patients with PSA >2 ng/ml, PSAdt ≤6 months and PSAve >2 ng/ml per year. CT is useful for detecting bone metastases that are not 18F-choline-avid. The use of intravenous contrast agent seems unnecessary.


18F-choline PET/CT Prostate cancer PSA kinetics Radical prostatectomy Contrast-enhanced CT 


Conflicts of interest



  1. 1.
    Reske SN, Blumstein NM, Neumaier B, Gottfried HW, Finsterbusch F, Kocot D, et al. Imaging prostate cancer with 11C-choline PET/CT. J Nucl Med. 2006;47:1249–54.PubMedGoogle Scholar
  2. 2.
    Amling CL, Blute ML, Bergstralh EJ, Seay TM, Slezak J, Zincke H. Long-term hazard of progression after radical prostatectomy for clinically localized prostate cancer: continued risk of biochemical failure after 5 years. J Urol. 2000;164:101–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Rogers R, Grossfeld GD, Roach M, Shinohara K, Presti Jr JC, Carroll PR. Radiation therapy for the management of biopsy proved local recurrence after radical prostatectomy. J Urol. 1998;160:1748–53.PubMedCrossRefGoogle Scholar
  4. 4.
    Schillaci O, Simonetti G. Fusion imaging in nuclear medicine – applications of dual-modality systems in oncology. Cancer Biother Radiopharm. 2004;19:1–10.PubMedCrossRefGoogle Scholar
  5. 5.
    DeGrado TR, Baldwin SW, Wang S, Orr MD, Liao RP, Friedman HS, et al. Synthesis and evaluation of 18F-labeled choline analogs as oncologic PET tracers. J Nucl Med. 2001;42:1805–14.PubMedGoogle Scholar
  6. 6.
    Jana S, Blaufox MD. Nuclear medicine studies of the prostate, testes, and bladder. Semin Nucl Med. 2006;36:51–72.PubMedCrossRefGoogle Scholar
  7. 7.
    Langsteger W, Beheshti M, Nader M, Stoiber F, Loidl W, Fitz F, et al. Evaluation of lymph node and bone metastases with fluor choline (FCH) PET-CT in the follow up of prostate cancer patients. Eur J Nucl Med Mol Imaging. 2006;33 Suppl 2:209.Google Scholar
  8. 8.
    Cimitan M, Bortolus R, Morassut S, Canzonieri V, Garbeglio A, Baresic T, et al. [(18)F]fluorocholine PET/CT imaging for the detection of recurrent prostate cancer at PSA relapse: experience in 100 consecutive patients. Eur J Nucl Med Mol Imaging. 2006;33:1387–98.PubMedCrossRefGoogle Scholar
  9. 9.
    Vees H, Bucheggert F, Albrecht S, Khan H, Husarik D, Zaidi H, et al. 18F-choline and/or 11C-acetate positron emission tomography: detection of residual or progressive subclinical disease at very low prostate-specific antigen values (< 1ng/ml) after radical prostatectomy. BJU Int. 2007;99:1415–20.PubMedCrossRefGoogle Scholar
  10. 10.
    Schillaci O, Calabria F, Tavolozza M, Cicciò C, Carlani M, Caracciolo CR, et al. 18F-choline PET/CT physiological distribution and pitfalls in image interpretation: experience in 80 patients with prostate cancer. Nucl Med Commun. 2010;31:39–45.PubMedCrossRefGoogle Scholar
  11. 11.
    Svatek R, Karakiewicz PI, Shulman M, Karam J, Perrotte P, Benaim E. Pre-treatment nomogram for disease-specific survival of patients with chemotherapy-naive androgen independent prostate cancer. Eur Urol. 2006;49:666–74.PubMedCrossRefGoogle Scholar
  12. 12.
    Van den Bergh RC, Roemeling S, Roobol MJ, Wolters T, Schröder FH, Bangma CH. Prostate-specific antigen kinetics in clinical decision-making during active surveillance for early prostate cancer – a review. Eur Urol. 2008;54:505–16.PubMedCrossRefGoogle Scholar
  13. 13.
    Liauw SL. Salvage radiotherapy for biochemical failure of radical prostatectomy: a single-institution experience. Urology. 2003;61:1204–10.PubMedCrossRefGoogle Scholar
  14. 14.
    Laufer M. Management of patients with rising prostate-specific antigen after radical prostatectomy. Urology. 2000;55:309–15.PubMedCrossRefGoogle Scholar
  15. 15.
    Critz FA. Prostate specific antigen nadir achieved by men apparently cured of prostate cancer by radiotherapy. J Urol. 1999;161:1199–203.PubMedCrossRefGoogle Scholar
  16. 16.
    Hövels AM, Heesakkers RAM, Andag EM, Jager GJ, Strum S, Hoogeveen YL, et al. The diagnostic accuracy of CT and MRI in the staging of pelvic lymph nodes in patients with prostate cancer: a meta-analysis. Clin Radiol. 2008;63:387–95.PubMedCrossRefGoogle Scholar
  17. 17.
    Beheshti M, Vali R, Waldenberger P, Fitz F, Nader M, Loidl W, et al. Detection of bone metastases in patients with prostate cancer by 18F fluorocholine and 18F fluoride PET-CT: a comparative study. Eur J Nucl Med Mol Imaging. 2008;35:1766–74.PubMedCrossRefGoogle Scholar
  18. 18.
    Moul JW. Prostate specific antigen only progression of prostate cancer. J Urol. 2000;163:1632–42.PubMedCrossRefGoogle Scholar
  19. 19.
    Hanks GE, D’Amico A, Epstein BE, Schultheiss TE. Prostate specific antigen doubling time in patients with prostate cancer: a potential useful reflection of tumour doubling time. Int J Radiat Oncol Biol Phys. 1993;27:125–7.PubMedGoogle Scholar
  20. 20.
    Roberts SG, Blute ML, Bergstralh EJ, Slezak JM, Zincke H. PSA doubling time as a predictor of clinical progression after biochemical failure following radical prostatectomy for prostate cancer. Mayo Clin Proc. 2001;76:576–81.PubMedGoogle Scholar
  21. 21.
    King CR, Presti JC, Brooks JD, Gill H, Spiotto MT. Postoperative prostate-specific antigen velocity independently predicts for failure of salvage radiotherapy after prostatectomy. Int J Radiat Oncol Biol Phys. 2008;70:1472–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Schoder H, Herrmann K, Gonen M, Hricak H, Eberhard S, Scardino P, et al. 2-[18F]fluoro-2-deoxyglucose positron emission tomography for the detection of disease in patients with prostate-specific antigen relapse after radical prostatectomy. Clin Cancer Res. 2005;11:4761–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Salminen E, Hogg A, Binns D, Frydenberg M, Hicks R. Investigations with FDG-PET scanning in prostate cancer show limited value for clinical practice. Acta Oncol. 2002;41:425–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Picchio M, Messa C, Landoni C, Gianolli L, Sironi S, Brioschi M, et al. Value of [11C]choline-positron emission tomography for re-staging prostate cancer: a comparison with [18F]fluorodeoxyglucose-positron emission tomography. J Urol. 2003;169:1337–40.PubMedCrossRefGoogle Scholar
  25. 25.
    Schoder H, Larson SM. Positron emission tomography for prostate, bladder, and renal cancer. Semin Nucl Med. 2004;34:274–92.PubMedCrossRefGoogle Scholar
  26. 26.
    Husarik DB, Miralbell R, Dubs M, John H, Giger OT, Gelet A, et al. Evaluation of [18F]-choline PET/CT for staging and restaging of prostate cancer. Eur J Nucl Med Mol Imaging. 2008;35:253–63.PubMedCrossRefGoogle Scholar
  27. 27.
    Pelosi E, Arena V, Skanjeti A, Pirro V, Douroukas A, Pupi A, et al. Role of whole-body 18F-choline PET/CT in disease detection in patients with biochemical relapse after radical treatment for prostate cancer. Radiol Med. 2008;113:895–904.PubMedCrossRefGoogle Scholar
  28. 28.
    De Jong IJ, Pruim J, Elsinga PH, Vaalburg W, Mensink HJ. 11C-choline positron emission tomography for the evaluation after treatment of localized prostate cancer. Eur Urol. 2003;44(1):32–8;38–9.Google Scholar
  29. 29.
    Krause BJ, Souvatzoglou M, Tuncel M, Herrmann K, Buck AK, Praus C, et al. The detection rate of [11C]choline-PET/CT depends on the serum PSA-value in patients with biochemical recurrence of prostate cancer. Eur J Nucl Med Mol Imaging. 2008;35:18–23.PubMedCrossRefGoogle Scholar
  30. 30.
    Picchio M, Briganti A, Fanti S, Heidenreich A, Krause BJ, Messa C, et al. The role of choline positron emission tomography/computed tomography in the management of patients with prostate-specific antigen progression after radical treatment of prostate cancer. Eur Urol. 2011;59:51–60.PubMedCrossRefGoogle Scholar
  31. 31.
    Freedland SJ, Humphreys EB, Mangold LA, Eisenberger M, Dorey FJ, Walsh PC, et al. Risk of prostate cancer-specific mortality following biochemical recurrence after radical prostatectomy. JAMA. 2005;294:433–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Albertsen PC, Hanley JA, Penson DF, Fine J. Validation of increasing prostate specific antigen as a predictor of prostate cancer death after treatment of localized prostate cancer with surgery or radiation. J Urol. 2004;171(6 Pt 1):2221–5.PubMedCrossRefGoogle Scholar
  33. 33.
    Wo JY, Chen MH, Nguyen PL, Renshaw AA, Loffredo MJ, Kantoff PW, et al. Evaluating the combined effect of comorbidity and prostate-specific antigen kinetics on the risk of death in men after prostate-specific antigen recurrence. J Clin Oncol. 2009;27:6000–5.PubMedCrossRefGoogle Scholar
  34. 34.
    Benchikh El Fegoun A, Villers A, Richaud P, Rebillard X, Beuzeboc P. PSA and follow-up after treatment of prostate cancer. Prog Urol. 2008;18:137–44.PubMedCrossRefGoogle Scholar
  35. 35.
    Partin AW, Pearson JD, Landis PK, Carter HB, Pound CR, Clemens JQ, et al. Evaluation of serum prostate-specific antigen velocity after radical prostatectomy to distinguish local recurrence from distant metastases. Urology. 1994;43:649–59.PubMedCrossRefGoogle Scholar
  36. 36.
    Okotie OT, Aronson WJ, Wieder JA, Liao Y, Dorey F, De Kernion JB, et al. Predictors of metastatic disease in men with biochemical failure following radical prostatectomy. J Urol. 2004;171:2260–4.PubMedCrossRefGoogle Scholar
  37. 37.
    Mottet N, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, et al. EAU guidelines on prostate cancer. Part II: Treatment of advanced, relapsing, and castration-resistant prostate cancer. Eur Urol. 2011;59:572–83.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Orazio Schillaci
    • 1
    • 2
  • Ferdinando Calabria
    • 2
    Email author
  • Mario Tavolozza
    • 1
  • Cristiana Ragano Caracciolo
    • 1
  • Enrico Finazzi Agrò
    • 3
  • Roberto Miano
    • 3
  • Antonio Orlacchio
    • 1
  • Roberta Danieli
    • 1
  • Giovanni Simonetti
    • 1
  1. 1.Department of Biopathology and Diagnostic Imaging, InterventionalUniversity “Tor Vergata”RomeItaly
  2. 2.Department of Nuclear Medicine and Molecular ImagingIRCCS NeuromedPozzilliItaly
  3. 3.Department of UrologyUniversity Hospital “Tor Vergata”RomeItaly

Personalised recommendations