PET/CT Variants and Pitfalls in Prostate Cancer: What You Might See on PET and Should Never Forget

Abstract

2-deoxy-2-[¹⁸F]fluorodeoxyglucose (FDG) positron emission tomography (PET) gained an impressive role in the diagnostic management of many oncological diseases, even though its use in imaging prostate cancer (PC) is limited to selected cases, mostly advanced stage of PC and selection for prostate specific antigen membrane (PSMA) radioligand therapy (RLT). In the past years, several PET tracers have been developed for both staging and restaging PC. The three most employed PET molecules in daily practice are [¹¹C] or [¹⁸F]F-Choline, [¹⁸F]F-Fluciclovine (Anti-1- amino-3-[18F]Fluorocyclobutane-1-Carboxylic Acid, also known as (Anti-[¹⁸F]FACBC), [⁶⁸Ga]Ga-PSMA and recently FDA approved the first Fluorinated PSMA-based named [¹⁸F]F-DCFPyl. Each one has its own physiological and peculiarity which are worth exploring. Moreover, an increasing number of case reports and studies have reported tracers' variants, pitfalls, or even non-prostatic diseases (benign and malignant) incidentally detected. In prostate oncology, PET can be performed with several indications in different stages of disease, as highlighted in the EAU Guidelines on PC. A correct scan interpretation depends on the knowledge of both the physiological distribution of the tracers and the uptake of possible variants and pitfalls. The aim of this critical review is to provide a comprehensive knowledge of physiological distribution of these three tracers, as well as an updated overview of variants and pitfalls.