INTERESTING IMAGE
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Ga-PSMA PET/CT False-Positive Tracer
Uptake in Paget Disease
Arun Sasikumar, MD, Ajith Joy, DRM, Raviteja Nanabala, MSc, M.R.A Pillai, PhD, and Hari T.A, MD
Abstract: 65-year-old man with left-sided pelvic pain on evaluation was
found to have features suggestive of either Paget disease or prostatic bone
metastasis of the left hemipelvis based on 99mTc-MDP bone scan and
MRI. 68Ga-PSMA PET/CT to assess the possibility of primary prostate
cancer and if present to stage it helped to rule out prostate cancer because
of absence of focal abnormal increased tracer uptake in the prostate gland.
However, false-positive tracer uptake was noted in the left hemipelvis,
which was subject to biopsy and histopathologically proven to be Paget
disease involvement.
Key Words: 68Ga-PSMA PET/CT, false-positive uptake, Paget disease
(Clin Nucl Med 2016;41: e454–e455)
Received for publication February 26, 2016; revision accepted June 22, 2016.
From the KIMS-DDNMRC, KIMS Hospital, Thiruvananthapuram, Kerala, India.
Conflicts of interest and sources of funding: none declared.
Correspondence to: Arun Sasikumar, MD, KIMS-DDNMRC, KIMS Hospital,
North Block, Anayara PO, Thiruvananthapuram, Kerala, India 695029. E-mail:
sasikumararun@gmail.com.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0363-9762/16/4110–e454
DOI: 10.1097/RLU.0000000000001340
10. Artigas C, Alexiou J, Garcia C, et al. Paget bone disease demonstrated on
e454 www.nuclearmed.com Clinical Nuclear Medicine • Volume 41, Number 10, October 2016
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Clinical Nuclear Medicine • Volume 41, Number 10, October 2016 False-Positive Tracer Uptake in Paget Disease

FIGURE 1. A 65-year-old man presented with history of left-sided pelvic pain of 1 month’s duration. He underwent an
MRI of the pelvis, which showed diffuse marrow signal alteration in the left iliac bone. A possibility of Paget disease and skeletal
metastasis was suggested from the MRI scans. He further underwent a 99mTc-MDP bone scan (A), which showed diffusely
increased osteoblastic activity in the left hemipelvis mainly in the left iliac bone. Bone scan findings again suggested the
possibilities of Paget disease or osteoblastic metastases from prostate cancer. His serum prostate-specific antigen levels was
0.5 ng/mL and serum alkaline phosphatase levels were only mildly elevated (148 IU). A 68 Ga-PSMA PET/CT was done to look
for any primary lesion in the prostate gland, as well as to stage the disease if present. 68Ga-PSMA PET/CT (B) showed no
focal abnormal tracer uptake in the prostate gland; however, heterogeneous moderate to intense tracer uptake was noted in
moderate sclerotic changes in the left iliac bone (C–H). A Trucut biopsy of the bone was obtained from the left iliac bone lesion,
which proved to be Paget disease in histopathologic examination. 68Ga-labeled Prostate specific membrane antigen (PSMA)
has redefined the paradigm of imaging in prostate cancer patients. 68Ga-PSMA imaging is now known to have a definitive role in
evaluation of recurrent prostate cancer patients.1,2 Recently the application of 68Ga-PSMA PET/CT in prostate cancer has been
expanded to include radiotherapeutic management of prostate cancer patients.3 68Ga-PSMA PET/CT reinforces the theranostics
principle, and consequent management of hormone refractory prostate cancer with 177Lu-PSMA has become possible.
177
Lu-PSMA–based therapy has shown promising results in initial analysis.4 The application of 68Ga-PSMA PET/CT is no longer
restricted to prostate cancer. PSMA expression in nonprostatic malignancies is described and is probably related to overexpression
of PSMA in the endothelial cells of tumor neovasculature, probably stimulated by secreted angiogenic factors during tumor
growth.5 Intense tracer uptake in 68Ga-PSMA PET/CT has been described in metastatic breast cancer, glioma, metastatic clear cell
carcinoma, and primary hepatocellular carcinoma.6–9 However, the possibility of PSMA overexpression in nonmalignant processes
is not well evaluated. Recently, a case of intense tracer uptake in 68Ga-PSMA PET/CT in a known case of Paget disease of phalanx
has been reported. Probable mechanism hypothesized for the intense tracer uptake in 68Ga-PSMA PET/CT is overexpression of
PSMA molecule in the pagetic bone, which is highly vascularized and undergoing remodeling.10 Our case highlights the fact
that possibility of false-positive tracer uptake in nonneoplastic bone condition such as Paget disease should be kept in mind while
reporting 68Ga-PSMA PET/CT scans in prostate cancer patients. The final impression of the study should be made in such cases
after corroborating the clinical, biochemical, and imaging parameters and may even warrant histopathologic confirmation
regarding the nature of the bone lesion in equivocal cases especially when the findings are expected to change the
management in the patient.

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