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  • Review Article
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Bone imaging in prostate cancer

Nature Clinical Practice Urology volume 5, pages 434–444 (2008)Cite this article

Abstract

Bone metastases of solid tumors are common, and about 80% of them occur in patients with breast, lung or prostate cancer. Bone metastases can be suspected clinically and by laboratory tests; however, a final diagnosis relies on radiographic evidence. Bone metastases of prostate cancer usually have osteoblastic characteristics, manifested by pathological bone resorption and formation. Conventional bone scans (e.g. with 99mTc-labeled methylene diphosphonate) are preferred to plain-film radiography for surveillance of the entire skeleton. Radiologic diagnosis of bone metastases, particularly in patients with low burden of disease, is difficult because noncancerous bone lesions that mimic cancer are common. Conventional bone scans are limited by their low sensitivity and high false-negative rate (up to 40%) compared with advanced bone-imaging modalities such as PET, PET–CT and MRI, which might assist or replace conventional scanning methods. The correct diagnosis of bone involvement in prostate cancer is crucial to assess the effects of therapy on the primary tumor, the patient's prognosis, and the efficacy of bone-specific treatments that can reduce future bone-associated morbidity. In addition, predictive tools such as nomograms enable the identification of patients at risk of bone involvement during the course of their disease. Such tools may limit treatment costs by avoidance of unnecessary tests and might reduce both short-term and long-term complication rates.

Key Points

  • Bone metastases are common in patients with advanced prostate cancer, and diagnosis of such metastases currently relies on imaging studies

  • The most commonly used bone-imaging modality in prostate cancer is the radionuclide bone scan, because this technique is easily available and inexpensive; however, radionuclide bone scans have limited sensitivity and specificity

  • Modern imaging modalities such as PET, PET–CT and MRI have improved accuracy in the detection of bone metastases of prostate cancer; however, these techniques have major limitations including high cost and lack of availability

  • Staging of newly diagnosed prostate cancer is usually done according to the patient's PSA level at diagnosis, digital rectal examination and biopsy results, which considerably reduces the number of tests performed

  • The prevalence of bone involvement in patients who have rising PSA levels after radical prostatectomy is associated with several clinical variables, the most important of which are dynamic changes in PSA (PSA doubling time and PSA velocity); these variables were used to construct a nomogram used to predict the probability of bone involvement at any specific time point, to determine whether patients require bone imaging, and to select patients for clinical trials

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Figure 1: Progression of bone involvement in a patient with prostate cancer.
Figure 2: Imaging results for an 82-year-old patient with bone metastases.
Figure 3: Bone-scan nomogram based on 414 bone scans of 239 patients observed at our institution.

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Authors and Affiliations

  1. ZA Dotan is Head of the Uro-oncology Service in the Department of Urology at Sheba Medical Center, Tel Hashomer, Israel,

    Zohar A Dotan

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Correspondence to Zohar A Dotan.

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Dotan, Z. Bone imaging in prostate cancer. Nat Rev Urol 5, 434–444 (2008). https://doi.org/10.1038/ncpuro1190

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