11C-Choline PET/CT in patients with hormone-resistant prostate cancer showing biochemical relapse after radical prostatectomy

  • Francesco Ceci
  • Paolo CastellucciEmail author
  • Marcelo Mamede
  • Riccardo Schiavina
  • Domenico Rubello
  • Chiara Fuccio
  • Valentina Ambrosini
  • Stefano Boschi
  • Giuseppe Martorana
  • Stefano Fanti
Original Article



To determine the diagnostic efficacy of 11C-choline PET/CT in patients with prostate cancer (PC) after radical prostatectomy who presented with increasing PSA levels during follow-up in spite of being on hormone treatment (HT), and therefore showing HT resistance.


We evaluated a large series of 157 consecutive PC patients previously treated by radical prostatectomy who presented with biochemical recurrence with increasing PSA levels in spite of ongoing HT (HT-resistant patients). At the time of 11C-choline PET/CT, the mean value of trigger PSA level was 8.3 (range  0.2 – 60.6 ng/mL), the mean PSA doubling time (PSAdt) was 5.3  (range  0.4 – 35 months), and the mean PSA velocity (PSAvel) was 22.1 ng/mL/year (range 0.12 – 82 ng/mL/year). 11C-Choline PET/CT was performed following a standard procedure at our centre to investigate increasing PSA levels, either as the first imaging procedure or in patients with negative conventional imaging. At the time of 11C-choline PET/CT all patients were receiving HT (61 were receiving monotherapy and 96 multidrug therapy). PET-positive findings were validated by: (a) transrectal US-guided biopsy in patients with recurrence in the prostatic bed, (b) surgical pelvic lymphadenectomy, (c) other imaging modalities, including repeated 11C-choline PET/CT, performed during a minimum follow-up of 12-months.


11C-Choline PET/CT showed positive findings in 104 of the 157 patients (66 %). 11C-choline PET/CT detected: a single lesion in 40 patients (7 in the prostate bed, 10 in lymph nodes, 22 in bone, 1 at another site); two lesions in 18 patients (7 in lymph nodes, 7 in bone, 4 in both lymph nodes and bone); three or four lesions in 7 patients (4 in lymph nodes, 2 in bone, 1 at another site); and more than four lesions in the remaining 39 patients (2 in the prostate bed, 12 in lymph nodes, 12 in bone, 11 in both lymph nodes and bone, 2 at other sites). In 11C-choline PET-negative patients, the mean values of trigger PSA, PSAdt and PSAvel were 3.8 ng/mL (range 0.2 – 11.9 ng/mL) 7.0 months (range 1.21 – 35 months) and 5.8 ng/mL/year (range 0.12 – 30.1) respectively, while in 11C-Choline-PET-positive patients they were 10.5 ng/mL (range 0.2 – 60.6), 4.4 months (range 0.4 – 19.7) and 15.9 ng/mL/year (range 0.5 – 82.0) respectively. The differences between PET-negative and PET-positive patients were statistically significant for all these parameters: trigger PSA, p < 0.01; PSAdt, p < 0.01; PSAvel, p = 0.03.


In our patient population, 11C-choline PET/CT was able to detect relapsed disease in a large proportion of HT-resistant PC patients during HT. These data, obtained in a large series, suggest that HT withdrawal before performing a 11C-choline PET/CT scan may not be necessary for the detection of recurrent disease if PSA levels are increasing and PSA kinetics are rapid.


Prostate cancer Radical prostatectomy Hormone therapy resistance 11C-Choline PET/CT Biochemical relapse, triggers PSA PSA kinetics 


Conflicts of interest



  1. 1.
    Kataja VV, Bergh J. ESMO Minimum Clinical Recommendations for diagnosis, treatment and follow-up of prostate cancer. Ann Oncol. 2005;16 Suppl 1:i34–6.PubMedCrossRefGoogle Scholar
  2. 2.
    Freedland SJ, Presti Jr JC, Amling CL, Aronson WJ, Dorey F, et al. Time trends in biochemical recurrence after radical prostatectomy: results of the SEARCH database. Urology. 2003;61:736–41.PubMedCrossRefGoogle Scholar
  3. 3.
    Han M, Partin AW, Zahurak M, Piantadosi S, Epstein JI, Walsh PC. Biochemical (prostate specific antigen) recurrence probability following radical prostatectomy for clinically localized prostate cancer. J Urol. 2003;169:517–23.PubMedCrossRefGoogle Scholar
  4. 4.
    Chism DB, Hanlon AL, Horwitz EM, Feigenberg SJ, Pollack A. A comparison of the single and double factor high-risk models for risk assignment of prostate cancer treated with 3D conformal radiotherapy. Int J Radiat Oncol Biol Phys. 2004;59(20):380–5.PubMedCrossRefGoogle Scholar
  5. 5.
    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
  6. 6.
    Sella T, Schwartz LH, Swindle PW, Onyebuchi CN, Scardino PT, Scher HI, et al. Suspected local recurrence after radical prostatectomy: endorectal coil MR imaging. Radiology. 2004;233:379–85.CrossRefGoogle Scholar
  7. 7.
    Coakley FV, Teh HS, Qayyum A, Swanson MG, Lu Y, Roach 3rd M, et al. Endorectal MR imaging and MR spectroscopic imaging for locally recurrent prostate cancer after external beam radiation therapy: preliminary experience. Radiology. 2004;233:441–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Choueiri TK, Dreicer R, Paciorek A, Carroll PR, Konety B. A model that predicts the probability of positive imaging in prostate cancer cases with biochemical failure after initial definitive local therapy. J Urol. 2008;179:906–10.PubMedCrossRefGoogle Scholar
  9. 9.
    Okotie OT, Aronson WJ, Wieder JA, Liao Y, Freedland SJ, Dekernion JB, et al. Predictors of metastatic disease in men with biochemical failure following radical prostatectomy. J Urol. 2004;171:2260–4.PubMedCrossRefGoogle Scholar
  10. 10.
    Heidenreich A, Bastian PJ, Bellmunt J, Bolla M, Joniau S, Mason MD, et al. Guidelines on prostate cancer. Eur Urol. 2011;59(1):61–71.Google Scholar
  11. 11.
    Cimitan M, Bortolus R, Morassut S, Canzonieri V, Garbeglio A, Baresic T, et al. 18Ffluorocholine 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
  12. 12.
    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
  13. 13.
    Giovacchini G, Picchio M, Scattoni V, Garcia Parra R, Briganti A, Gianolli L, et al. PSA doubling time for prediction of [(11)C]choline PET/CT findings in prostate cancer patients with biochemical failure after radical prostatectomy. Eur J Nucl Med Mol Imaging. 2010;37:1106–16.PubMedCrossRefGoogle Scholar
  14. 14.
    Castellucci P, Fuccio C, Nanni C, Santi I, Rizzello A, Lodi F, et al. Influence of trigger PSA and PSA kinetics on 11C-choline PET/CT detection rate in patients with biochemical relapse after radical prostatectomy. J Nucl Med. 2009;50:1394–400.PubMedCrossRefGoogle Scholar
  15. 15.
    Picchio M, Messa C, Landoni C, Gianolli L, Sironi S, Brioschi M, et al. Value of 11Ccholine-positron emission tomography for re-staging prostate cancer: a comparison with 18Ffluorodeoxyglucose-positron emission tomography. J Urol. 2003;169:1337–40.PubMedCrossRefGoogle Scholar
  16. 16.
    Pascali C, Bogni A, Itawa R, Cambiè M, Bombardieri E. [11C]Methylation on a C18 Sep-Pak cartridge: a convenient way to produce N-methyl-11Ccholine. J Labelled Comp Radiopharm. 2000;49:195–203.CrossRefGoogle Scholar
  17. 17.
    Khan MA, Carter HB, Epstein JI, Miller MC, Landis P, Walsh PW, et al. Can prostate specific antigen derivatives and pathological parameters predict significant change in expectant management criteria for prostate cancer? J Urol. 2003;170:2274–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Hara T, Kosaka N, Kishi H. PET imaging of prostate cancer using carbon-11-choline. J Nucl Med. 1998;39:990–5.PubMedGoogle Scholar
  19. 19.
    Krause BJ, Souvatzoglou M, Tuncel M, Herrmann K, Buck AK, Praus C, et al. The detection rate of 11Ccholine-PET/TC 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
  20. 20.
    Soyka JD, Muster MA, Schmid DT, Schick U, Miralbell R. Clinical impact of 18F-choline PET/CT in patients with recurrent prostate cancer. Eur J Nucl Med Mol Imaging. 2012;39:936–43.PubMedCrossRefGoogle Scholar
  21. 21.
    DeGrado TR, Coleman RE, Wang S, Baldwin SW, Orr MD, Robertson CN, et al. Synthesis and evaluation of 18F-labeled choline as an oncologic tracer for positron emission tomography: initial findings in prostate cancer. Cancer Res. 2001;61:110–7.PubMedGoogle Scholar
  22. 22.
    De Waele A, Van Binnebeek S, Mottaghy FM. Response assessment of hormonal therapy in prostate cancer by [11C]choline PET/CT. Clin Nucl Med. 2010;35:701–3.PubMedCrossRefGoogle Scholar
  23. 23.
    Giovacchini G, Picchio M, Coradeschi E, Scattoni V, Bettinardi V, Cozzarini C, et al. [(11)C]choline uptake with PET/CT for the initial diagnosis of prostate cancer: relation to PSA levels, tumour stage and anti-androgenic therapy. Eur J Nucl Med Mol Imaging. 2008;35:1065–73.PubMedCrossRefGoogle Scholar
  24. 24.
    Fuccio C, Schiavina R, Castellucci P, Rubello D, Martorana G, Celli M, et al. Androgen deprivation therapy influences the uptake of 11C-choline in patients with recurrent prostate cancer: the preliminary results of a sequential PET/CT study. Eur J Nucl Med Mol Imaging. 2011;38:1985–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Giovacchini G, Picchio M, Coradeschi E, Bettinardi V, Gianolli L, Scattoni V, et al. Predictive factors of [(11)C]choline PET/CT in patients with biochemical failure after radical prostatectomy. Eur J Nucl Med Mol Imaging. 2010;37:301–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Castellucci P, Fuccio C, Rubello D, Schiavina R, Santi I, Nanni C, et al. Is there a role for 11C-choline PET/CT in the early detection of metastatic disease in surgically treated prostate cancer patients with a mild PSA increase <1.5ng/ml? Eur J Nucl Med Mol Imaging. 2011;38:55–63.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Francesco Ceci
    • 1
  • Paolo Castellucci
    • 1
    • 6
    Email author
  • Marcelo Mamede
    • 2
  • Riccardo Schiavina
    • 3
  • Domenico Rubello
    • 4
  • Chiara Fuccio
    • 5
  • Valentina Ambrosini
    • 1
  • Stefano Boschi
    • 1
  • Giuseppe Martorana
    • 3
  • Stefano Fanti
    • 1
  1. 1.Nuclear Medicine Unit, Department of Haematology Oncology and Laboratory Medicine, Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant’Orsola-MalpighiUniversity of BolognaBolognaItaly
  2. 2.Molecular Imaging CenterUniversidade Federal de Minas GeraisBelo HorizonteBrazil
  3. 3.Department of Urology, Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant’Orsola-MalpighiUniversity of BolognaBolognaItaly
  4. 4.Department of Nuclear Medicine & PET/CT Centre‘Santa Maria della Misericordia’ HospitalRovigoItaly
  5. 5.Service of Nuclear MedicineFondazione Salvatore MaugeriPaviaItaly
  6. 6.UO di Medicina Nucleare, PAD. 30Azienda Ospedaliero-Unversitaria di Bologna Policlinico Sant’Orsola-MalpighiBolognaItaly

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