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| Practice patterns and outcomes of equivocal bone scans for patients with castration-resistant prostate cancer: Results from SEARCH |
Brian T. Hanyoka,b,Mary M. Everista,Lauren E. Howarda,c,Amanda M. De Hoedta,William J. Aronsond,e,Matthew R. Cooperbergf,g,Christopher J. Kaneh,Christopher L. Amlingi,Martha K. Terrisj,k,Stephen J. Freedlanda,l,m,*( )
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aUrology Section, Department of Surgery, Veterans Affairs Medical Center, Durham, NC, USA
bNew York Medical College, Valhalla, NY, USA
cDepartment of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
dUrology Section, Department of Surgery, Veterans Affairs Medical Center, Greater Los Angeles, Los Angeles, CA, USA
eDepartment of Urology, University of California at Los Angeles Medical Center, Los Angeles, CA, USA
fDepartments of Urology and Epidemiology & Biostatistics, University of California, San Francisco, CA, USA
gUrology Section, Department of Surgery, Veterans Affairs Medical Center, San Francisco, CA, USA
hDivision of Urology, Department of Surgery, University of California at San Diego Medical Center, San Diego, CA, USA
iDivision of Urology, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
jUrology Section, Division of Surgery, Veterans Affairs Medical Center, Augusta, GA, USA
kDivision of Urologic Surgery, Department of Surgery, Medical College of Georgia, Augusta, GA, USA
lDivision of Urology, Department of Surgery, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
mCenter for Integrated Research in Cancer and Lifestyle, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA |
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Abstract Objective: To review follow-up imaging after equivocal bone scans in men with castration resistant prostate cancer (CRPC) and examine the characteristics of equivocal bone scans that are associated with positive follow-up imaging. Methods: We identified 639 men from five Veterans Affairs Hospitals with a technetium-99m bone scan after CRPC diagnosis, of whom 99 (15%) had equivocal scans. Men with equivocal scans were segregated into “high-risk” and “low-risk” subcategories based upon wording in the bone scan report. All follow-up imaging (bone scans, computed tomography [CT], magnetic resonance imaging [MRI], and X-rays) in the 3 months after the equivocal scan were reviewed. Variables were compared between patients with a positive vs. negative follow-up imaging after an equivocal bone scan. Results: Of 99 men with an equivocal bone scan, 43 (43%) received at least one follow-up imaging test, including 32/82 (39%) with low-risk scans and 11/17 (65%) with high-risk scans (p = 0.052). Of follow-up tests, 67% were negative, 14% were equivocal, and 19% were positive. Among those who underwent follow-up imaging, 3/32 (9%) low-risk men had metastases vs. 5/11 (45%) high-risk men (p = 0.015). Conclusion:While 19% of all men who received follow-up imaging had positive follow-up imaging, only 9% of those with a low-risk equivocal bone scan had metastases versus 45% of those with high-risk. These preliminary findings, if confirmed in larger studies, suggest follow-up imaging tests for low-risk equivocal scans can be delayed while high-risk equivocal scans should receive follow-up imaging.
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Received: 26 February 2018
Available online: 18 January 2019
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Corresponding Authors:
Stephen J. Freedland
E-mail: stephen.freedland@cshs.org
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| Characteristic | Data (n = 99) | | Age (year) | 78 (69-84) | | Year | 2006 (2004-2010) | | Race | | non-African American | 60 (61%) | | African American | 38 (39%) | | PSA (ng/mL) | 9.2 (4.8-21.2) | | PSADTa (month) | 11.0 (5.1-27.6) | | Risk rating of equivocal scan | | Low | 82 (83%) | | High | 17 (17%) | | Received follow-up imaging | 43 (43%) | | Negative | 29 (67%) | | Equivocal | 6 (14%) | | Positive | 8 (19%) | | Type of follow-up imagingb | | X-ray | 32 (58%) | | Bone scan | 8 (15%) | | MRI | 5 (9%) | | CT | 10 (18%) |
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Patient characteristics at time of equivocal bone scan.
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| Clinical factors | Follow-up imaging test result | p-Value | | Negative, n = 35 (81%) | Positive, n = 8 (19%) | | Age (year) | 80 (71-84) | 71 (67-78) | 0.091 | | Year | 2006 (2004-2010) | 2006 (2005-2009) | 0.851 | | PSA (ng/mL) | 7.9 (5.4-14.8) | 14.4 (9.6-27.8) | 0.086 | | PSADTa (month) | 11.1 (6.2-15.8) | 16.7 (4.4-28.8) | 0.608 | | High-risk equivocal bone scan rating | | | 0.017 | | Low | 29 (91%) | 3 (9%) | | | High | 6 (55%) | 5 (45%) | | | Follow-up scan within 1 week | | | 0.612 | | No | 29 (81%) | 7 (19%) | | | Yes | 6 (86%) | 1 (14%) | |
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Associations between clinical factors and follow-up imaging test outcome.
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| Type | Low-risk | High-risk | | positive/performed (%) | positive/performed (%) | | X-ray | 2/25 (8) | 1/7 (14) | | Bone scan | 2/6 (33) | 1/2 (50) | | MRI | 1/3 (33) | 1/2 (50) | | CT | 1/7 (14) | 2/3 (67) |
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Type of follow-up imaging test and outcome stratified by low- and high-risk.
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| Definition | Example(s) | | High-risk equivocal definition | The radiology report identifies two or more possible diagnoses, but it suggests that prostate cancer metastases are more likely than the alternatives. | (a)
“…suspicion for a metastasis, although it could also represent degenerative change.”
(b)
“…concern is for metastases, however trauma cannot be excluded.”
(c)
“…consistent with metastatic disease given the patient's history, however, the differential diagnosis does include Paget's disease.” | | Low-risk equivocal definition, Part 1 | The radiology report identifies two or more possible diagnoses, but it suggests that prostate cancer metastases are less likely than the alternatives. | (a)
“This is likely degenerative, however an early metastasis cannot be entirely excluded.”
(b)
“…may be due to post-traumatic changes or less likely a small met.”
(c)
“…more suggestive of Paget's disease than mets, although the latter or a combination of both cannot be excluded.” | | Low-risk equivocal definition, Part 2 | The radiology report suggests that prostate cancer metastases and another diagnosis are equally likely. | “…nonspecific and may result from focal metastasis or fracture.” | | Low-risk equivocal definition, Part 3 | The radiology report does not specifically identify prostate cancer metastases as a possible diagnosis, but it describes the findings as abnormal in the context of a prostate cancer metastatic evaluation. | “Abnormal radiotracer uptake in a linear vertical configuration within the sternum.” | | Low-risk equivocal definition, Part 4 | The radiology report identifies only prostate cancer metastases as a possible explanation of abnormal findings, but it explicitly states that metastases are unlikely. | “These findings are of unknown significance and would be an unusual presentation of metastatic disease.” |
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Definitions of “low-risk” and “high-risk” ratings of equivocal bone scan radiology reports.
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