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Purpose <p>Conventional <sup>99m</sup>Tc-methylene diphosphonate (<sup>99m</sup>Tc-MDP) bone scintigraphy reflects osteoblastic activity but lacks tumor specificity, which may result in false-positive findings and overstaging in high-risk prostate cancer. Prostate-specific membrane antigen (PSMA)-targeted imaging enables tumor-specific detection; however, its incremental clinical value relative to conventional <sup>99m</sup>Tc-MDP bone scintigraphy remains uncertain, particularly in settings where bone scintigraphy remains the primary skeletal staging modality. We prospectively evaluated the diagnostic performance and potential impact on skeletal metastatic classification of <sup>99m</sup>Tc-PSMA compared with <sup>99m</sup>Tc-MDP bone scintigraphy in treatment-naïve patients with unfavorable intermediate-, high-, and very high-risk prostate cancer.</p> Methods <p>Sixty-eight newly diagnosed patients, stratified by NCCN risk criteria, underwent both <sup>99m</sup>Tc-PSMA and <sup>99m</sup>Tc-MDP scintigraphy. Skeletal metastatic status was determined using longitudinal clinical and imaging follow-up as a composite reference standard. Patient-level agreement, diagnostic performance, and lesion-level positive predictive value were assessed.</p> Results <p>Skeletal metastases were confirmed in 33 of 68 patients (48.5%), with prevalence increasing significantly across NCCN risk groups (<i>p</i> &lt; 0.001). Inter-modality agreement was high (91.2%; κ = 0.82). All discordant cases were <sup>99m</sup>Tc-MDP-positive and<sup>99m</sup>Tc-PSMA-negative (6/68, 8.8%; <i>p</i> = 0.031) and were adjudicated as non-metastatic on follow-up. Overall, <sup>99m</sup>Tc-MDP resulted in 7 false-positive patient-level skeletal metastatic classifications, compared with 1 false-positive classification with &#xa0;<sup>99m</sup>Tc-PSMA. Sensitivity was 100% for both modalities. Specificity was higher for <sup>99m</sup>Tc-PSMA than for <sup>99m</sup>Tc -MDP bone scintigraphy (97.1% vs. 80.0%), as was positive predictive value (97.1% vs. 82.5%); negative predictive value was 100% for both. At the lesion level, <sup>99m</sup>Tc -MDP demonstrated a higher false-positive proportion than <sup>99m</sup>Tc -PSMA (26.4% vs. 3.7%), resulting in lower lesion-level positive predictive value (73.6% vs. 96.3%).</p> Conclusion <p>In this prospective cohort, <sup>99m</sup>Tc -PSMA demonstrated sensitivity comparable to that of <sup>99m</sup>Tc-bone scintigraphy for detecting skeletal metastases, with higher specificity and fewer false-positive findings. These results suggest that <sup>99m</sup>Tc-PSMA may offer a more tumor-targeted alternative to conventional bone scintigraphy for skeletal staging in appropriately selected treatment-naïve patients, particularly in settings where bone scintigraphy remains the primary modality for assessment of skeletal metastases.</p>

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Prospective comparison of 99mTc-PSMA and 99mTc-MDP scintigraphy for detection of skeletal metastases in treatment-naïve patients with unfavorable intermediate-, high-, and very high-risk prostate cancer

  • 期刊论文

  • 发表日期：

    2026年7月22日

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  • David R. Cardoza-Ochoa,
  • Martín R. González-Martínez,
  • Alicia A. Bautista-Tejeda,
  • Norman E. Becerra-Osorio,
  • Suelem C. Oñate-Angulo,
  • Sergio A. López-Buenrostro,
  • Andres Ricaurte-Fajardo,
  • Jorge I. González-Díaz

摘要

Purpose

Conventional 99mTc-methylene diphosphonate (99mTc-MDP) bone scintigraphy reflects osteoblastic activity but lacks tumor specificity, which may result in false-positive findings and overstaging in high-risk prostate cancer. Prostate-specific membrane antigen (PSMA)-targeted imaging enables tumor-specific detection; however, its incremental clinical value relative to conventional 99mTc-MDP bone scintigraphy remains uncertain, particularly in settings where bone scintigraphy remains the primary skeletal staging modality. We prospectively evaluated the diagnostic performance and potential impact on skeletal metastatic classification of 99mTc-PSMA compared with 99mTc-MDP bone scintigraphy in treatment-naïve patients with unfavorable intermediate-, high-, and very high-risk prostate cancer.

Methods

Sixty-eight newly diagnosed patients, stratified by NCCN risk criteria, underwent both 99mTc-PSMA and 99mTc-MDP scintigraphy. Skeletal metastatic status was determined using longitudinal clinical and imaging follow-up as a composite reference standard. Patient-level agreement, diagnostic performance, and lesion-level positive predictive value were assessed.

Results

Skeletal metastases were confirmed in 33 of 68 patients (48.5%), with prevalence increasing significantly across NCCN risk groups (p < 0.001). Inter-modality agreement was high (91.2%; κ = 0.82). All discordant cases were 99mTc-MDP-positive and99mTc-PSMA-negative (6/68, 8.8%; p = 0.031) and were adjudicated as non-metastatic on follow-up. Overall, 99mTc-MDP resulted in 7 false-positive patient-level skeletal metastatic classifications, compared with 1 false-positive classification with  99mTc-PSMA. Sensitivity was 100% for both modalities. Specificity was higher for 99mTc-PSMA than for 99mTc -MDP bone scintigraphy (97.1% vs. 80.0%), as was positive predictive value (97.1% vs. 82.5%); negative predictive value was 100% for both. At the lesion level, 99mTc -MDP demonstrated a higher false-positive proportion than 99mTc -PSMA (26.4% vs. 3.7%), resulting in lower lesion-level positive predictive value (73.6% vs. 96.3%).

Conclusion

In this prospective cohort, 99mTc -PSMA demonstrated sensitivity comparable to that of 99mTc-bone scintigraphy for detecting skeletal metastases, with higher specificity and fewer false-positive findings. These results suggest that 99mTc-PSMA may offer a more tumor-targeted alternative to conventional bone scintigraphy for skeletal staging in appropriately selected treatment-naïve patients, particularly in settings where bone scintigraphy remains the primary modality for assessment of skeletal metastases.