Utility of F-18 FDG PET/CT for Detection of Bone Marrow Metastases in Prostate Cancer Patients Treated with Radium-223

Document Type : Case report


1 Department of Radiology, Kansai Medical University, JAPAN

2 Department of Urology, Kansai Medical University, JAPAN

3 Departments of Urology, Kansai Medical University, JAPAN


A 76-year-old man with symptomatic bone metastases from castrationresistant prostate cancer underwent Radium-223-dichloride (Ra-223) therapy. Before Ra-223 therapy, he had normal peripheral blood cell counts. Ra-223 therapy relieved his shoulder and low back pain. The elevation of the serum prostate-specific antigen (PSA), doubling every month during Ra-223 therapy, suggested a PSA flare or relapse. Some lesions showed decrease and some lesions showed increase on Tc-99m hydroxymethylene diphosphonate bone scintigraphy at two weeks after the third injection of Ra-223 therapy. Ra-223 therapy was discontinued due to thrombocytopenia that was getting worse rapidly. After treatment discontinuation, namely four weeks after the third injection of Ra-223, F-18 fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)/CT and a biopsy were performed to evaluate for metastases, and bone marrow metastases were found. Ra-223 was effective for osteoblastic lesions, but not for bone marrow metastases. FDG PET/CT, but not a Tc-99m based bone scan, detected diffuse bone marrow involvement by cancer. This case report is the first to clarify the utility of FDG PET for the detection of bone marrow metastases confirmed by pathological examination in Ra-223 therapy for progressive castration-resistant prostate cancer.


Main Subjects


    1. Pacilio M, Ventroni G, Cassano B, Ialongo P, Lorenzon L, Di Castro E, et al. A case report of image-based dosimetry of bone metastases with Alpharadin ((223)Ra-dichloride) therapy: inter-fraction variability of absorbed dose and follow-up. Ann Nucl Med. 2016;30(2):163-8.
    2. Hobbs RF, Song H, Watchman CJ, Bolch WE, Aksnes AK, Ramdahl T, et al. A bone marrow toxicity model for ²²³Ra alpha-emitter radiopharmaceutical therapy. Phys Med Biol. 2012;57(10):3207-22.
    3. Parker C, Nilsson S, Heinrich D, Helle SI, O’Sullivan JM, Fosså SD, et al. Alpha emitter radium-223 and survival in metastatic prostate cancer. N Engl J Med. 2013;369(3):213-23.
    4. McNamara MA, George DJ. Pain, PSA flare, and bone scan response in a patient with metastatic castration-resistant prostate cancer treated with radium-223, a case report. BMC Cancer. 2015;15:371.
    5. Keizman D, Fosboel MO, Reichegger H, Peer A, Rosenbaum E, Desax MC, et al. Imaging response during therapy with radium-223 for castration-resistant prostate cancer with bone metastases-analysis of an international multicenter database. Prostate Cancer Prostatic Dis. 2017;20(3):289-93.
    6. Coleman R, Aksnes AK, Naume B, Garcia C, Jerusalem G, Piccart M, et al. A phase IIa, nonrandomized study of radium-223 dichloride in advanced breast cancer patients with bone-dominant disease. Breast Cancer Res Treat. 2014;145(2):411-8.
    7. Hsu WK, Virk MS, Feeley BT, Stout DB, Chatziioannou AF, Lieberman JR. Characterization of osteolytic, osteoblastic, and mixed lesions in a prostate cancer mouse model using 18F-FDG and 18F-fluoride PET/ CT. J Nucl Med. 2008;49(3):414-21.
    8. Kaur G, Basu S, Kaur P, Sood T. Metastatic bone marrow tumors: study of nine cases and review of the literature. J Blood Disord Transfus. 2011;2(110):2.
    9. Burgio SL, Conteduca V, Rudnas B, Carrozza F, Campadelli E, Bianchi E, et al. PSA flare with abiraterone in patients with metastatic castration-resistant prostate cancer. Clin Genitourin Cancer. 2015;13(1):39-43.
    10. Common terminology criteria for adverse events v3.0 (CTCAE). New York: Cancer Therapy Evaluation Program (CTEP); 2006.
    11. Zhang L, Chen L, Xie Q, Zhang Y, Cheng L, Li H, et al. A comparative study of 18F-fluorodeoxyglucose positron emission tomography/computed tomography and (99m)Tc-MDP whole-body bone scanning for imaging osteolytic bone metastases. BMC Med Imaging. 2015;15:7.
    12. Nome R, Hernes E, Bogsrud TV, BjøroT, Fosså SD. Changes in prostate-specific antigen, markers of bone metabolism and bone scans after treatment with radium-223. Scand J Urol. 2015;49(3):211-7.