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The central zone has increased 68Ga-PSMA-11 uptake: “Mickey Mouse ears” can be hot on 68Ga-PSMA-11 PET

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Abstract

Purpose

Given the good correlation between PSMA expression and intraglandular tumour aggressiveness based on immunohistochemistry, there is increasing interest in 68Ga-PSMA-11 PET/MRI for staging prostate cancer (PCA). Therefore, accurate knowledge of prostate anatomy as well as normal distribution of PSMA within the prostate gland is becoming essential. The aim of this study was to investigate the physiological intraprostatic distribution of 68Ga-PSMA-11.

Methods

We retrospectively analysed all patients who underwent a staging 68Ga-PSMA-11 PET/MRI scan between June 2016 and January 2018 for high-risk PCA, underwent radical prostatectomy in our institution, and gave written consent for further data analysis. In each patient, standardized volumes of interest (VOIs) were placed bilaterally in the central, transition and peripheral zones within the zonal anatomy according to T2 weighted sequences in the axial and coronal planes. VOIs were only placed if they were safely within healthy tissue without spillover from the PCA. SUVmax and SUVmean were determined and their differences among the regions were assessed using the Wilcoxon signed-ranks test.

Results

Of 283 consecutive patients scanned with 68Ga-PSMA-11 PET/MR, 31 were analysed. A total of 133 VOIs were placed, 46 in the central zone, 41 in the transition zone and 46 in the peripheral zone. Differences in SUVmax between the central zone (mean 3.9 ± 0.58) and transition zone (mean 3.2 ± 0.59) and between the central zone and peripheral zone (mean 2.7 ± 0.54) were statistically significant (both p < 0.001).

Conclusion

Our results suggest that higher 68Ga-PSMA-11 accumulation in the central zone than in the transition and peripheral zones is normal, and leads to a pattern resembling “Mickey Mouse ears” on 68Ga-PSMA-11 PET. This pattern could be helpful in avoiding false-positive interpretations of PET scans.

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Acknowledgments

The authors acknowledge the technicians Marlena Hofbauer, Miguel Porto, Sofia Kaltsuni, Tobias Oblasser, Sabrina Epp, Michele Hug and Melanie Thüringer for their excellent work providing high-quality PET/MRI data. The Department of Nuclear Medicine holds an institutional Research Contract with GE Healthcare.

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Authors and Affiliations

  1. Department of Nuclear Medicine, University Hospital Zürich, University of Zürich, Rämistrasse 100, 8091, Zürich, Switzerland

    Daniele A. Pizzuto, Julian Müller, Urs Mühlematter, Hannes Nagel & Irene A. Burger

  2. Department of Nuclear Medicine, Università Cattolica del Sacro Cuore, Rome, Italy

    Daniele A. Pizzuto

  3. Department of Pathology and Molecular Pathology, University Hospital Zürich, University of Zürich, Rämistrasse 100, 8091, Zürich, Switzerland

    Niels J. Rupp & Antonia Töpfer

  4. Department of Urology, University Hospital Zürich, University of Zürich, Rämistrasse 100, 8091, Zürich, Switzerland

    Ashkan Mortezavi, Benedikt Kranzbühler & Daniel Eberli

Authors
  1. Daniele A. Pizzuto
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  2. Julian Müller
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  10. Irene A. Burger
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Corresponding author

Correspondence to Irene A. Burger.

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Conflicts of interest

I.A.B. received research grants and speaker honoraria from GE Healthcare. All other authors declare no conflicts of interest.

Ethical approval

This retrospective study was approved by the local ethics committee (BASEC Nr. 2016-02231).

Informed consent

All patients gave a written informed general consent for retrospective analysis of their data.

Electronic supplementary material

Supplementary Fig. 1

All patients with high urinary activity (SUVmax >25) are included to demonstrate the lack of any halo artefact despite high accumulation of 68Ga-PSMA-11 in the bladder. Axial and coronal slices are shown at the level of the bladder using a PET window of 0–8 g/ml in (a) patient 13 (SUVmax 27), (b) patient 17 (SUVmax 32), (c) patient 9 (SUVmax 33), and (d) patient 23 (SUVmax 57) (GIF 125 kb)

High resolution image (TIFF 1.48 mb)

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Pizzuto, D.A., Müller, J., Mühlematter, U. et al. The central zone has increased 68Ga-PSMA-11 uptake: “Mickey Mouse ears” can be hot on 68Ga-PSMA-11 PET. Eur J Nucl Med Mol Imaging 45, 1335–1343 (2018). https://doi.org/10.1007/s00259-018-3979-2

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  • DOI: https://doi.org/10.1007/s00259-018-3979-2

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