Comparison of PSMA-based F-DCFPyL PET/CT and Tc-99m MDP Bone Scan in Detection of Bone Metastasis in Prostate Cancer

While Tc-99m MDP bone scan (BS) remains the conventional standard for detection of bone metastasis in prostate cancer, newly FDA-approved imaging with PSMA-based F-DCFPyL PET/CT has shown promise for early detection of metastatic disease. However, a paucity of data remains in the diagnostic accuracy of PSMA PET/CT in detecting bone metastasis compared to BS. This retrospective study included 91 patients who received both BS and PSMA PET/CT within a 3-month interval from August 2021 to February 2022. Separate concurrent primary cancer, interval PSA levels greater than a 2-fold difference (or absolute difference >1 ng/ml) between the two studies were excluded. All abnormal bone lesions on either scan were compared. The findings were verified by pathological findings and/or 6-month clinical follow-up. High concordance (78%) was found between modalities with discordant findings (20/91, 22%) demonstrating more false positives (4/20, 20%) and false negatives (3/20, 15%) on BS compared to PET/CT. Additionally, more bone metastases were detected on PSMA PET/CT (13/20, 65%) with all true positive BS lesions also detected PET/CT. The sensitivity, specificity, PPV and NPV for BS were 89%, 91%, 80%, and 95% respectively; and 100%, 97%, 93%, and 100% for F-DCFPyL PET/CT respectively. Our results demonstrate that F-DCFPyL PET/CT identified more bone metastases while also identifying all bone metastases identified on BS. With the added diagnostic value of detecting primary tumor and soft tissue metastasis, F-DCFPyL PET/CT may render BS unnecessary to investigate bone metastases in patients with prostate cancer.