Die Cholin-PET/CT für Diagnostik, Staging und Restaging des Prostatakarzinoms

Zusammenfassung

Die rechtzeitige Diagnose und ein adäquates Staging des Prostatakarzinoms sind essenzielle Voraussetzungen für die Wahl des optimalen Therapieverfahrens. Die Verwendung von F-18 und C-11 markierten Cholinderivaten in der PET/CT-Diagnostik hat in den letzten Jahren zunehmend Einzug in die Diagnostik des Prostatakarzinoms genommen. Der Nutzen der Cholin-PET/CT in der Primärdiagnostik wurde in vielen Studien kontrovers diskutiert. Im Großteil der Studien zeigte sich eine Limitation in der Diagnose des Primärtumors, insbesondere in Abhängigkeit der Tumorkonfiguration (kleine und schalenförmige Tumoren) und in der Abgrenzung zu benignen Läsionen (BPH, HG-PIN, Prostatitis), sodass sich hier kein regulärer Einsatz in der diagnostischen Routine empfiehlt. Auch für die Detektion von Lymphknotenmetastasen ergibt sich in der Primärsituation nur eine eingeschränkte Sensitivität der Cholin-PET-CT (bei adäquater Spezifität). Hier kann die Cholin-PET/CT ggf. bei High-risk-Patienten vor Therapie/im Rahmen der Therapieplanung eingesetzt werden. Beim Restaging des Prostatakarzinoms bei biochemischem Rezidiv stellt die Cholin-PET/CT ein bedeutendes Verfahren dar. Die Detektionsrate ist hierbei abhängig vom PSA-Wert, der PSA-Kinetik und der PSA-Verdopplungszeit, ebenso vom initialen Gleason-Score, sodass die Detektionsrate auch bei einem PSA<1 ng/ml von insgesamt ca. 30% in Kombination mit einem höheren Gleason-Score auf bis zu 50% ansteigt. Im Restaging bei biochemischem Rezidiv zeigt sich eine gute Sensitivität und Spezifität. Die Cholin-PET/CT führt hierbei in bis zu 60% der Fälle zur Änderung bzw. Anpassung des Therapieregimes, z. B. im Rahmen der Bestrahlungsplanung. Für die fortgeschrittene Tumorerkrankung mit ossärer Metastasierung ergibt sich ebenfalls eine hohe Spezifität für die Cholin-PET/CT, bez. der Sensitivität ist diese jedoch der Skelettszintigrafie einschließlich SPECT unterlegen. Erste Daten deuten außerdem darauf hin, dass sich ein signifikanter Überlebensvorteil für Patienten ergibt, die bei PSA-Anstieg keine vermehrte Cholin-Aufnahme zeigen.

Abstract

Early diagnosis and accurate staging are crucial for the optimal choice of treatment in prostate cancer. F-18 and C-11 labelled choline derivatives are increasingly used for PET/CT imaging. The value of choline PET/CT in primary staging of prostate cancer is actually discussed controversially. Most studies have shown a limited sensitivity of choline PET/CT in primary diagnosis depending on the tumor configuration (especially small and rim-like tumors) and a limited specificity in the differentiation between prostate cancer and benign prostate lesions such as BPH, HGPIN and prostatitis. Due to the limited specificity, routine use of choline PET/CT is not recommended. With respect to nodal staging, sensitivity of choline PET/CT is limited in the primary setting, although the specificity is adequate. However, choline PET/CT might be used in staging of high risk patients before therapy planning. Sensitivity and specificity of choline PET/CT is valuable in restaging patients with biochemical recurrence. The detection rate depends on the PSA serum level, PSA kinetics and PSA doubling time as well as on the Gleason score. Detection rate in patients with a PSA level>1 ng/ml ranges between 30 and 50% (dependent on Gleason score). Choline PET/CT leads to a change of treatment in up to 60% of patients, i. e. in radiation treatment planning. In case of advanced disease choline PET/CT has a high specificity in the detection of bone metastases, however, bone scintigraphy (SPECT) provides higher sensitivity. Preliminary data have shown a significant better survival in patients with biochemical recurrence and negative findings in choline PET/CT.

Schlüsselwörter

Prostatakarzinom - Cholin - PET/CT

Key words

prostate cancer - choline - PET/CT

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