Skeletal tumor burden on baseline 18F-fluoride PET/CT predicts bone marrow failure after 223Ra therapy

Elba C. Etchebehere, John C. Araujo, Denái R. Milton, William D. Erwin, Richard E. Wendt, Nancy M. Swanston, Patricia Fox, Homer A. Macapinlac, Eric M. Rohren

Research output: Contribution to journalArticlepeer-review

26 Scopus citations


Purpose: Determine if skeletal tumor burden on 18F-fluoride PET/CT (fluoride PET/CT) predicts the risk of bone marrow failure (BMF) after 223Ra dichloride therapy (223Ra). Methods: Forty-one metastatic prostate cancer patients (43-89 years old; mean, 71 ± 9 years.) underwent fluoride PET/CT prior to 223Ra. Bone marrowfailurewas the primary end point and was defined as (1) development of hematologic toxicity (World Health Organization grade 3 or 4) associated with no recovery after 6 weeks or (2) death due to BMF after the last 223Ra dose. Bone marrow failurewas correlated to fluoride PET/CT skeletal tumor burden (TLF10 [total lesion on fluoride PET/CT with SUVmax of 10 or greater]), use of chemotherapy, serum hemoglobin concentration, serum ALP, and serum prostate-specific antigen. Results: The number of 223Ra cycles ranged from 2 to 6 (mean, 5). Of the 41 patients, 16 developedBMF (G3 = 12; G4 = 4). A significantly increased risk of developing BMF was observed in patients with TLF10 of 12,000 or greater (hazard ratio [HR], 11.09; P < 0.0001), hemoglobin of less than 10 g/dL (HR, 7.35; P = 0.0002), and AP > 146 UI/L (HR, 4.52; P = 0.0100). Neither concomitant (HR, 0.91; P = 0.88) nor subsequent use of chemotherapy (HR, 0.14; P = 0.84) increased the risk of BMF, nor was prostate-specific antigen greater than 10 μg/L (HR, 0.90; P = 0.86). Moreover, in a multivariable analysis, TLF10 was the only independent predictor of BMF (HR, 6.66; P = 0.0237). Conclusions: 223Rawas beneficial and reduced the risk of death even in patients with a high skeletal tumor burden. Fluoride PET/CT is able to determine which patients will benefit from 223Ra and which will develop BMF.

Original languageEnglish (US)
Pages (from-to)268-273
Number of pages6
JournalClinical Nuclear Medicine
Issue number4
StatePublished - Mar 4 2016


  • Bone marrow failure
  • Bone metastases
  • Fluoride PET/CT
  • Prostate cancer
  • Ra
  • Skeletal tumor burden

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging


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