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Review article
The role of positron emission tomography/computed tomography imaging with radiolabeled choline analogs in prostate cancer
Papel de la tomografía por emisión de positrones/tomografía computarizada con análogos radiomarcados de colina en el cáncer de próstata
M.M. Navarro-Pelayo Láineza,
Corresponding author
mnavarropelayo@gmail.com

Corresponding author.
, A. Rodríguez-Fernándeza, M. Gómez-Ríoa, F. Vázquez-Alonsob, J.M. Cózar-Olmob, J.M. Llamas-Elviraa
a Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, Spain
b Servicio de Urología, Hospital Universitario Virgen de las Nieves, Granada, Spain
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">73-Year-old patient with newly diagnosed prostate cancer &#40;PSA&#58; 11&#46;95<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#59; Gleason&#58; 4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>5&#59; clinical stage&#58; T3a&#41; under study due to initial staging&#46; <span class="elsevierStyleSup">18</span>F-fluorocholine-PET&#47;CT examination shows in its axial sections of PET &#40;A&#41;&#44; CT &#40;B&#41;&#44; and fusion &#40;F&#41; a focal increase of uptake in the left lobe of the prostate gland &#40;maxSUV&#58; 6&#46;72&#41;&#44; compatible with the neoplastic activity already known at this location&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Epidemiology</span><p id="par0005" class="elsevierStylePara elsevierViewall">Prostate cancer &#40;PC&#41; is one of the most important medical problems of the male population today&#46; It is the most common solid tumor in the European Union and it causes a significant number of deaths in industrialized countries&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The diagnostic instruments to obtain signs of this cancer include digital rectal examination &#40;DRE&#41;&#44; serum prostate specific antigen &#40;PSA&#41; concentration&#44; and transrectal ultrasound&#59; however&#44; definitive diagnosis is based on the presence of adenocarcinoma in the prostate biopsy&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Initial staging</span><p id="par0015" class="elsevierStylePara elsevierViewall">Local staging &#40;T staging&#41; of PC is based on the results of TR and MR&#46; Possibly the latter is the technique of choice for the correct delimitation of its extension&#44; as the new techniques&#8212;endorectal coils&#44; spectroscopy&#44; and combination of MR with dynamic contrast and enhanced MR in T2&#8212;offer better results in terms of PC staging&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The nodal status &#40;N staging&#41; is especially important when a potentially curative treatment is expected&#46; Conventional imaging tests have limitations in detection of metastases &#60;5<span class="elsevierStyleHsp" style=""></span>mm&#44; so that the pelvic lymphadenectomy remains the most reliable method&#59; however&#44; it is still a controversial and invasive procedure with regard to the most appropriate technique to perform &#40;standard or extended&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Metastatic bone site is the most frequent in PC&#44; and the best way to evaluate it is the bone scan&#44; which has traditionally shown a high sensitivity&#46; In contrast&#44; it seems not to be indicated in asymptomatic patients when the serum PSA concentration is &#60;20<span class="elsevierStyleHsp" style=""></span>ng&#47;ml in well or moderately differentiated tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Biochemical recurrence</span><p id="par0030" class="elsevierStylePara elsevierViewall">Tumor recurrence is an event that occurs in 20&#8211;50&#37; of patients after radical prostatectomy &#40;RP&#41; and in more than 30&#8211;40&#37; of those who received external beam radiotherapy &#40;RT&#41;&#46; After a RP&#44; only 2 consecutive values &#62;0&#46;2<span class="elsevierStyleHsp" style=""></span>ng&#47;ml represent a recurrent cancer&#46; However&#44; the failure of RT has been redefined several times&#44; now being known as PSA elevation&#62;2<span class="elsevierStyleHsp" style=""></span>ng&#47;ml above the PSA nadir&#46; There is no consensus for the other treatments&#8212;cryotherapy or brachytherapy&#8212;and therefore it is not possible to give definite recommendations on biochemical failure in these cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Only the PSA concentration and&#44; ultimately&#44; the RT are the only tests to routinely be performed during the follow-up&#46; The identification and precise localization of recurrences has not yet been achieved&#46; CT has a low sensitivity and specificity in this context&#44; particularly if the size of the recurrence is &#60;2<span class="elsevierStyleHsp" style=""></span>cm&#46; For its part&#44; the MR is not a first-line diagnostic tool either&#44; although some authors suggest that the incorporation of endorectal coils makes it a sensitive and predictive technique in identifying recurrence after RP&#46; Bone scintigraphy is indicated in the control of symptomatic patients&#44; but we must remember that its low specificity sometimes determines the performance of additional examinations to verify the findings&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Radiopharmaceuticals for positron emission tomography in prostate cancer</span><p id="par0040" class="elsevierStylePara elsevierViewall">The multimodal technique positron emission tomography&#47;computed tomography &#40;PET&#47;CT&#41;&#44; which combines the performance of the anatomical and functional scans&#44; is emerging as a diagnostic tool useful in the study of PC&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Although the most widely used radiopharmaceutical is 2-&#91;<span class="elsevierStyleSup">18</span>F&#93;fluoro-2-deoxy-<span class="elsevierStyleSmallCaps">d</span>-glucose &#40;<span class="elsevierStyleSup">18</span>F-FDG&#41;&#44; it is not routinely used in PC&#46; Affinity for the carbohydrate tracer is related to the glucose transporter expression of the membrane &#40;GLUT-1&#41;&#44; present in greater amount in the poorly differentiated hormone-independent cell lines than in well-differentiated hormone-sensitive ones&#46; The lower uptake of <span class="elsevierStyleSup">18</span>F-FDG in PC&#44; compared with other tumors&#44; has been attributed to the fact that this malignancy has a slower metabolism and a lower expression of GLUT-1<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> transporters &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Physiological uptake of <span class="elsevierStyleSup">18</span>F-FDG is observed in viable tissues such as the brain&#44; myocardium&#44; liver&#44; gastrointestinal tract&#44; muscle&#44; and bone marrow&#46; Urinary excretion of the tracer is an added factor that reduces the efficiency of the technique&#44; since the intense activity in ureters and bladder can mask injuries in the prostate and surrounding tissues&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There is currently great interest in choline analogs&#46; Choline is introduced into the cell via specific transporters&#44; and once inside it is phosphorylated by the enzyme choline-kinase &#40;CK&#41; to yield phosphocholine&#46; This is the first step of the 3 that make up the so-called Kennedy pathway &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; enzymatic cascade&#44; whose final product is phosphatidylcholine or lecithin&#46; Phosphatidylcholine&#44; the main membrane phospholipid&#44; is synthesized in 2 steps by means of a catalyzed reaction by phosphocholine citidiltransferase and through phosphocholine transferase&#46; Although the specific mechanism by which the tracer uptake is produced is not sufficiently clarified&#44; it seems to be due to 2 situations that occur in proliferative processes&#58; increase in the transport and in the phosphorylation of choline&#8212;primarily due to the overexpression of CK&#8212;as well as increased need for lipid formation&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">No major differences were found in the biodistribution of the choline&#44; regardless of the isotope that it is marked with &#40;<span class="elsevierStyleSup">11</span>C or <span class="elsevierStyleSup">18</span>F&#41;&#44; except for physiological urinary elimination which is higher with <span class="elsevierStyleSup">18</span>F-fluorocholine&#46; Under normal conditions we can find an intense tracer uptake in the liver and pancreas&#44; being somewhat lower in the spleen&#44; salivary and lacrimal glands&#46; Tracer deposits in both kidneys&#44; ureters and bladder are considered equally physiological distribution&#46; Other less common locations but also described are the bone marrow &#40;dorsal vertebral level&#41; and the intestinal tract due to the high proliferation of the mucosa at this level &#40;especially important in the small intestine&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSup">11</span>C-choline is indistinguishable from the natural molecule of choline&#59; however&#44; its short half-life &#40;20<span class="elsevierStyleHsp" style=""></span>min&#41; causes frequent logistical problems&#44; since it forces to work in a center near a cyclotron&#46; Thus&#44; it is important to have radiopharmaceuticals with greater half life as <span class="elsevierStyleSup">18</span>F-fluorocholine &#40;110<span class="elsevierStyleHsp" style=""></span>min&#41; that can be transported to centers away from the producer cyclotron&#46; The increased urinary excretion of <span class="elsevierStyleSup">18</span>F-fluorocholine&#44; as explained&#44; can alter the results of the image in the pelvis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The present review aims to critically analyze the current evidence for the use of <span class="elsevierStyleSup">11</span>C and <span class="elsevierStyleSup">18</span>F-choline-PET&#47;CT in staging and suspected biochemical failure after treatment of PC&#44; as well as its role as a diagnostic tool in treatment strategies during follow-up&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Evidence of acquisition</span><p id="par0075" class="elsevierStylePara elsevierViewall">To select the bibliography used in the drafting of this article a thorough search was conducted in the scientific literature using the Medline database &#40;via Pubmed&#41;&#46; Relevant publications were collected by means of the inclusion of the following keywords</p><p id="par0080" class="elsevierStylePara elsevierViewall">Prostate cancer and Choline-PET&#44; to which we added the terms Biochemical failure and&#47;or Staging and&#47;or PSA kinetics&#44; arranged in different combinations&#46; Similarly&#44; we selected and critically reviewed the works in English and Spanish language published between 2008 and 2013&#46; Original articles&#44; reviews&#44; systematic reviews&#44; meta-analyses&#44; and clinical practice guidelines were included&#46; The studies published only as an abstract or the reports of the meetings were not taken into account&#46; In general&#44; the original ratio of bibliographic citations was discussed with all the authors to select the most relevant articles&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Evidence of synthesis</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Initial staging</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">T staging</span><p id="par0085" class="elsevierStylePara elsevierViewall">So far choline-PET&#47;CT is not a first-line diagnostic tool in the location of the primary tumor in patients with newly diagnosed PC&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In this neoplasia&#44; the presence of multiple foci of tumor is characteristic-most small-difficult to detect by PET&#47;CT&#44; especially those with mild uptake and size &#60;5<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Moreover&#44; its limited ability to distinguish between tumor tissue and benign prostatic diseases with affinity for the tracer &#40;prostatitis and benign prostatic hypertrophy&#41; often involves a high number of false positives&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Because of these limitations&#44; some groups have made technological innovations that make it possible to improve the results&#46; The &#8216;double phase&#8217; image acquisition &#40;with late projections at 90<span class="elsevierStyleHsp" style=""></span>min postinjection&#41; enables us to differentiate between benign and malignant tissue&#44; since over time the uptake of neoplastic lesions remains stable or even increases&#44; decreasing in benign areas&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">An application of choline-PET&#47;CT that increasingly becomes stronger is the location of the tumor focus in cases of high clinical suspicion of PC and at least 2 negative biopsies<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> in order to properly guide a new biopsy and increase the rate of detection<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">N staging</span><p id="par0100" class="elsevierStylePara elsevierViewall">The choline-PET&#47;CT is a reliable and non-invasive technique for nodal staging in patients with medium-high risk according to the D&#8217;Amico classification&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> especially if we consider that conventional imaging modalities have limitations in this context&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; the bowel activity and physiological excretion in the urinary system &#40;shown in the <span class="elsevierStyleSup">18</span>F-fluorocholine&#41;&#44; along with the frequent uptake in inflammatory nodes&#44; may interfere with the identification of the possible lymph node involvement&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Most analyzed studies show high specificity but low sensitivity among their results&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;14</span></a> In a recent systematic review&#44; values of sensitivity&#44; specificity&#44; positive predictive value &#40;PPV&#41;&#44; and negative predictive value &#40;NPV&#41; of 66&#44; 96&#44; 82 and 92&#37; respectively in the assessment of lymph nodes size &#62;5<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Therefore&#44; the choline can be useful for detecting metastatic nodal lesions of diameter &#8805;5<span class="elsevierStyleHsp" style=""></span>mm&#44; especially when dynamic acquisition or &#8220;dual stage&#8221;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; is performed&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">M staging</span><p id="par0110" class="elsevierStylePara elsevierViewall">The results about the usefulness of the choline-PET&#47;CT in M staging are consistent&#58; it is a useful technique to rule out distant metastases in patients at high risk candidates for surgical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Hodolic et al&#46; state that the sensitivity&#44; specificity&#44; and diagnostic accuracy of <span class="elsevierStyleSup">18</span>F-fluorocholine in detecting bone metastases is 74&#46;99 and 85&#37;&#44; respectively&#59; moreover&#44; they coincide with Beheshti et al&#46; that the technique appears to be superior to bone scintigraphy by demonstrating the marrow infiltration early&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In a recent cohort study <span class="elsevierStyleSup">18</span>F-fluorocholine modified the therapeutic approach in 20&#37; of the patients&#44; as it evidenced bone metastatic spread in patients with negative or inconclusive bone scintigraphy&#44; assuming the change of therapy with curative intent to palliative&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Again&#44; performing delayed images is of great importance by increasing the sensitivity in the detection of bone metastases&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Biochemical recurrence</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Recurrente location</span><p id="par0125" class="elsevierStylePara elsevierViewall">As shown in the literature&#44; the usefulness of choline-PET&#47;CT is clear in the detection of recurrence after RP&#44; as well as the relationship with the value of the PSA&#46; In fact&#44; in the work by Breeuwsma et al&#46; it is stated that a negative <span class="elsevierStyleSup">11</span>C-choline-PET&#47;CT correlates with a high disease-free survival and ensures reduced need for treatment in patients with suspected recurrence after RP&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> With a threshold of standard uptake value &#40;maxSUV&#41;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3 and a size of tumor focus &#62;1&#46;7<span class="elsevierStyleHsp" style=""></span>cm&#44; the sensitivity and specificity of <span class="elsevierStyleSup">11</span>C-choline in local recurrence after RP is 73 and 88&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Only in a recently published study that compared MRI with contrast and spectroscopy and <span class="elsevierStyleSup">18</span>F-fluorocholine-PET&#47;CT in patients with elevation of the PSA after RP&#44; the sensitivity of MRI is superior to that of PET in local recurrences &#60;10<span class="elsevierStyleHsp" style=""></span>mm&#44; with similar results in &#62;10<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The same cannot be said after RT&#44; the presence of inflammatory tissue after treatment being frequent with affinity for the radiopharmaceutical&#46; Therefore&#44; we can not make reliable final recommendations in these patients&#44; especially if we take into account the scarcity of published studies about it&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The choline-PET&#47;CT has a high PPV &#40;86&#37;&#41; in the identification and location of nodal recurrence after radical treatment &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; However&#44; in the analysis per lesions the NPVis low&#44; since it is not capable of detecting microscopic disease &#40;the mean diameter of the true positives is 15<span class="elsevierStyleHsp" style=""></span>mm&#44; while that of false negatives is 6&#46;3<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It is important to mention that we must be cautious in the evaluation of mediastinal lymph nodes&#44; where the presence of inflammatory&#47;reactive uptake is frequent&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">There are studies that have compared the bone scintigraphy and PET&#47;CT with choline during the follow-up of patients with previously treated PC&#46; Most authors are inclined to choline analogs&#44; showing an early assessment and a higher overall sensitivity in detecting bone metastases &#40;30 lesions with <span class="elsevierStyleSup">11</span>C-choline were observed&#44; not suspected by the scintigraphy&#44; in 14&#46;6&#37; of the patients analyzed in the study by Fuccio et al&#46;&#41;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; The results of another retrospective study showed a higher specificity and PPV of <span class="elsevierStyleSup">11</span>C-choline on bone scintigraphy&#44; being so that a positive result at the bone level is reliably considered by the authors as a malignant lesion&#44; even in the absence of confirmatory scans&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Selection of patients</span><p id="par0145" class="elsevierStylePara elsevierViewall">None of the risk factors for recurrence known&#8212;patient age &#40;&#62;65 years&#41;&#44; time between surgery and relapse&#44; previous biochemical failure&#44; Gleason score&#44; initial T and N stages&#8212;seems to influence the sensitivity of the test as the PSA value does&#46; However&#44; all these variables can be useful for the specialist&#44; helping to select candidates for conducting examination&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The authors assume that the higher the PSA value&#44; the greater the tissue metabolism&#44; and therefore the greater the avidity for <span class="elsevierStyleSup">18</span>F-fluorocholine&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> increasing the ability to detect recurrences&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; in those cases where the increase of the PSA is very discreet&#44; positive results must be validated with other techniques&#44; taking into account that the specificity and PPV of <span class="elsevierStyleSup">18</span>F-fluorocholine-PET&#47;CT decrease with low PSA values&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">If we analyze the works published to date&#44; we will realize that there is no consensus about the ideal cut-off point for the PSA value&#46; For their part&#44; Krause et al&#46; found a linear relationship between the value of the PSA and the positive results of the PET&#47;CT&#58; 36&#37; of the studies with PSA<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; 43&#37; with 1<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>PSA<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; 62&#37; with 2<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>PSA<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; and 73&#37; with PSA<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Other works&#44; like the previous one&#44; have described the relationship between the detection rate and the level of the PSA&#44; proving to be statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; and using as optimal cut-off point for the PSA a value of 2&#46;43<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Others go further&#44; detecting recurrences even with PSA<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>ng&#47;ml &#40;40&#37; of their series&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The analysis of the PSA kinetics using as parameters the ascent rate and doubling time &#40;PSAvel and PSAdt&#44; respectively&#41; may improve the selection of patients candidates for the technique&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The PSA kinetics can reliably stratify the probability of success of the choline-PET&#47;CT&#44; the PSAdt being<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>6 months the most significant predictive factor and that better reflects the natural growth pattern of recurrent disease&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">A review in which it is postulated that the choline-PET&#47;CT may be the first diagnostic technique to be chosen for suspected recurrence&#44; especially in cases of rapid kinetics&#44; despite having a slight increase in the PSA<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> has recently been published&#46; This hypothesis is endorsed by other studies showing that patients with positive PET&#47;CT have a rapid kinetics &#40;mean PSAdt&#58; 6 months&#59; mean PSAvel&#58; 9&#46;3<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#47;year&#41;&#44; being slow in negative scans &#40;mean PSAdt&#58; 15&#46;4 months&#59; mean PSAvel&#58; 0&#46;9<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#47;year&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Schillaci et al&#46;&#44; very close to the above findings&#44; confirm the close relationship between the PSA kinetics and the detection of <span class="elsevierStyleSup">18</span>F-fluorocholine and recommend the technique in patients with PSAdt<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>6 months and PSAvel<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#47;year&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Therapeutic implications</span><p id="par0170" class="elsevierStylePara elsevierViewall">We assessed the usefulness of the choline-PET&#47;CT as determining examination for the therapeutic strategy during the follow-up&#46; The results are promising&#44; because in 75 of the 156 patients analyzed &#40;48&#37;&#41; in a recent retrospective study the therapeutic plan was modified based on the findings of the functional technique and assuming a major impact on the treatment strategy of recurrent PC&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Other groups have analyzed the ability of the scan to differentiate local relapse and systemic&#44; finding that <span class="elsevierStyleSup">18</span>F-fluorocholine favorably determines the therapeutic approach for each patient&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Following these observations&#44; we believe that the distinction between local and systemic recurrence by choline-PET&#47;CT can help in the selection of candidates for new therapies&#44; being of particular interest in young patients where early institution of appropriate treatment can improve the quality of life&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">More and more people defend the usefulness of choline-PET&#47;CT in programming the RT&#44; even in patients who have received neoadjuvant hormone therapy &#40;HT&#41;&#46; <span class="elsevierStyleSup">11</span>C-choline determined a change in the extent of the target volume of the RT in 13&#37; of the patients analyzed&#44; in a retrospective study&#44; in whom there was suspicion of recurrence after RP&#46; Furthermore&#44; 75&#37; of the cases in which that volume increased&#44; according to the findings of the PET&#47;CT&#44; remained free of disease during the follow-up time&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Similarly <span class="elsevierStyleSup">11</span>F-fluorocholine behaves as a useful tool in the design of the irradiation field in patients with pelvic lymph nodes as recurrent disease&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Influence of hormone therapy</span><p id="par0180" class="elsevierStylePara elsevierViewall">The presence of HT is an aspect that can affect the diagnostic accuracy of the technique&#44; since the reduction in the choline uptake in response to a therapeutic androgen suppression appears to correlate with a reduction of the choline uptake&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Fuccio et al&#46;&#44; before a group of 14 patients with PSA increase after RP&#44; evaluated the influence of hormonal manipulation on the detection of recurrences&#44; conducting in all of them 2 PET&#47;CT studies &#40;before and 6 months after starting the HT&#41;&#46; Their findings lean toward a marked reduction in the choline uptake and a decrease in the PSA during the time of HT&#44; particularly in androgen-sensitive patients&#46; The withdrawal of the HT prior to the study appears to increase the detection rate&#44; the intensity of uptake of metastatic lesions and therefore the sensitivity of the test&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In the same vein&#44; the results of Giovacchini et al&#46; support the conclusion that the HT with bicalutamide is associated with a significant decrease in the choline uptake in the gland&#44; and confirm that this inhibition may also influence the uptake of lymph nodes or even bone&#46; The influence of the HT makes them think that choline-PET&#47;CT&#8211;in combination with the PSA&#8211; can be useful to assess the response to such treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">These same authors&#44; in a later work &#40;2012&#41;&#44; suggest that hormone-resistant patients with suspected biochemical failure are more likely to present a positive <span class="elsevierStyleSup">11</span>C-choline-PET&#47;CT study&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> These reflections coincide with those of the Ceci group&#44; since according to their results <span class="elsevierStyleSup">11</span>C-choline-PET&#47;CT can detect recurrence in a substantial proportion of hormone-resistant patients&#44; androgen withdrawal not being necessary whenever the PSA levels increase progressively and rapid kinetics is observed&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">However&#44; we observed some debate among some authors such as Henninger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> and the other groups&#46; The data of Henninger determine that the technique has an acceptable diagnostic accuracy in the detection of recurrences in patients with HT&#44; even when the PSA values are relatively low&#46; Moreover&#44; they found no statistically significant differences in the sensitivity of the 2 groups &#40;with and without HT&#41;&#44; in fact&#44; the sensitivity in treatment group was superior &#40;80 vs&#46; 50&#37; in the absence of HT&#41;&#46;</p></span></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclusions</span><p id="par0205" class="elsevierStylePara elsevierViewall">The use of PET&#47;CT with radiolabeled choline analogs provides promising results compared to <span class="elsevierStyleSup">18</span>F-FDG in PC&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The choline is not useful in the primary location of the tumor&#44; but it is in the identification of lymph node involvement in patients with newly diagnosed medium-high grade PC&#46; Its main advantage over other imaging techniques in the detection of bone metastases is the ability to demonstrate the marrow infiltration early&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The most important indication of the choline-PET&#47;CT in PC is the detection of biochemical recurrence&#44; conducting examination not being recommended when the values of this marker are &#60;1<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#46; Although the positivity of the test increases with the increase in the PSA value&#44; it is more useful to conduct a study of the kinetics when selecting the patients candidate for examination&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Finally&#44; and although it is necessary to conduct studies with confirmatory data&#44; the choline-PET&#47;CT is emerging as a diagnostic tool that can provide new and interesting opportunities in the planning of the individualized treatment of PC&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflict of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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        0 => array:2 [
          "identificador" => "xres378209"
          "titulo" => array:4 [
            0 => "Abstract"
            1 => "Introduction"
            2 => "Evidence acquisition"
            3 => "Conclusions"
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          "identificador" => "xpalclavsec357262"
          "titulo" => "Keywords"
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          "titulo" => array:4 [
            0 => "Resumen"
            1 => "Introducci&#243;n"
            2 => "Evidencia de adquisici&#243;n"
            3 => "Conclusiones"
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          "identificador" => "xpalclavsec357261"
          "titulo" => "Palabras clave"
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          "titulo" => "Introduction"
          "secciones" => array:7 [
            0 => array:2 [
              "identificador" => "sec0010"
              "titulo" => "Epidemiology"
            ]
            1 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Initial staging"
            ]
            2 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Biochemical recurrence"
            ]
            3 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Radiopharmaceuticals for positron emission tomography in prostate cancer"
            ]
            4 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Evidence of acquisition"
            ]
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              "identificador" => "sec0035"
              "titulo" => "Evidence of synthesis"
              "secciones" => array:1 [
                0 => array:3 [
                  "identificador" => "sec0040"
                  "titulo" => "Initial staging"
                  "secciones" => array:3 [
                    0 => array:2 [
                      "identificador" => "sec0045"
                      "titulo" => "T staging"
                    ]
                    1 => array:2 [
                      "identificador" => "sec0050"
                      "titulo" => "N staging"
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                    2 => array:2 [
                      "identificador" => "sec0055"
                      "titulo" => "M staging"
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              "identificador" => "sec0060"
              "titulo" => "Biochemical recurrence"
              "secciones" => array:4 [
                0 => array:2 [
                  "identificador" => "sec0065"
                  "titulo" => "Recurrente location"
                ]
                1 => array:2 [
                  "identificador" => "sec0070"
                  "titulo" => "Selection of patients"
                ]
                2 => array:2 [
                  "identificador" => "sec0075"
                  "titulo" => "Therapeutic implications"
                ]
                3 => array:2 [
                  "identificador" => "sec0080"
                  "titulo" => "Influence of hormone therapy"
                ]
              ]
            ]
          ]
        ]
        5 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Conclusions"
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        6 => array:2 [
          "identificador" => "sec0090"
          "titulo" => "Conflict of interest"
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        7 => array:1 [
          "titulo" => "References"
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    "fechaRecibido" => "2013-11-13"
    "fechaAceptado" => "2013-12-01"
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      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec357262"
          "palabras" => array:6 [
            0 => "Prostate cancer"
            1 => "Choline"
            2 => "PET&#47;CT"
            3 => "Biochemical relapse"
            4 => "Staging"
            5 => "PSA kinetics"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec357261"
          "palabras" => array:6 [
            0 => "C&#225;ncer de pr&#243;stata"
            1 => "Colina"
            2 => "PET&#47;TC"
            3 => "Recurrencia bioqu&#237;mica"
            4 => "Estadificaci&#243;n"
            5 => "Cin&#233;tica PSA"
          ]
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Prostate cancer is the most frequent solid malignant tumor in Western countries&#46; Positron emission tomography&#47;X-ray computed tomography imaging with radiolabeled choline analogs is a useful tool for restaging prostate cancer in patients with rising prostate-specific antigen after radical treatment &#40;in whom conventional imaging techniques have important limitations&#41; as well as in the initial assessment of a selected group of prostate cancer patients&#46; For this reason a literature review is necessary in order to evaluate the usefulness of this imaging test for the diagnosis and treatment of prostate cancer&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Evidence acquisition</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A MEDLINE &#40;PubMed way&#41; literature search was performed using the search parameters&#58; &#171;Prostate cancer&#187; and &#171;Choline-PET&#47;CT&#187;&#46; Other search terms were &#171;Biochemical failure&#187; and&#47;or &#171;Staging&#187; and&#47;or &#171;PSA kinetics&#187;&#46; English and Spanish papers were selected&#59; original articles&#44; reviews&#44; systematic reviews and clinical guidelines were included&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">According to available data&#44; radiolabeled choline analogs plays an important role in the management of prostate cancer&#44; especially in biochemical relapse because technique accuracy is properly correlated with prostate-specific antigen values and kinetics&#46; Although is an emerging diagnostic technique useful in treatment planning of prostate cancer&#44; final recommendations have not been submitted&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0030">Introducci&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El c&#225;ncer de pr&#243;stata es el tumor maligno s&#243;lido m&#225;s frecuente en los pa&#237;ses occidentales&#46; La tomograf&#237;a por emisi&#243;n de positrones&#47;tomograf&#237;a computarizada con an&#225;logos radiomarcados de colina es una herramienta &#250;til en la re-estadificaci&#243;n de pacientes con aumento del ant&#237;geno prost&#225;tico espec&#237;fico despu&#233;s de tratamiento radical&#8212;donde las t&#233;cnicas de imagen convencional tienen limitaciones importantes&#8212;as&#237; como en un seleccionado grupo de pacientes en la valoraci&#243;n inicial de esta neoplasia&#46; Esta situaci&#243;n nos lleva a plantear una revisi&#243;n de la literatura donde se eval&#250;e la utilidad de esta exploraci&#243;n en la toma de decisiones diagn&#243;stico-terap&#233;uticas en el c&#225;ncer de pr&#243;stata&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0035">Evidencia de adquisici&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Realizamos una b&#250;squeda bibliogr&#225;fica a trav&#233;s de la base de datos Medline &#40;v&#237;a Pubmed&#41; utilizando los t&#233;rminos <span class="elsevierStyleItalic">Prostate cancer</span> y <span class="elsevierStyleItalic">Choline-PET&#47;CT</span> a los que a&#241;adimos los t&#233;rminos <span class="elsevierStyleItalic">Biochemical failure</span> y&#47;o <span class="elsevierStyleItalic">Staging</span> y&#47;o <span class="elsevierStyleItalic">PSA kinetics</span>&#46; As&#237; mismo&#44; seleccionamos los trabajos en lengua inglesa y espa&#241;ola e incluimos art&#237;culos originales&#44; revisiones&#44; revisiones sistem&#225;ticas&#44; metaan&#225;lisis y gu&#237;as de pr&#225;ctica cl&#237;nica&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">De acuerdo con los datos disponibles los an&#225;logos radiomarcados de colina desempe&#241;an un papel importante en el manejo del c&#225;ncer de pr&#243;stata&#44; especialmente en la recurrencia bioqu&#237;mica&#44; donde la exactitud de la t&#233;cnica se correlaciona bien con el valor del ant&#237;geno prost&#225;tico espec&#237;fico y su cin&#233;tica&#46; Aunque esta t&#233;cnica se perfila como una modalidad diagn&#243;stica de aplicaci&#243;n en la planificaci&#243;n del tratamiento del c&#225;ncer de pr&#243;stata&#44; a&#250;n no se han realizado recomendaciones finales sobre su uso&#46;</p>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Navarro-Pelayo L&#225;inez MM&#44; Rodr&#237;guez-Fern&#225;ndez A&#44; G&#243;mez-R&#237;o M&#44; V&#225;zquez-Alonso F&#44; C&#243;zar-Olmo JM&#44; Llamas-Elvira JM&#46; Papel de la tomograf&#237;a por emisi&#243;n de positrones&#47;tomograf&#237;a computarizada con an&#225;logos radiomarcados de colina en el c&#225;ncer de pr&#243;stata&#46; Actas Urol Esp&#46; 2014&#59;38&#58;613&#8211;621&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Cell entrapment of <span class="elsevierStyleSup">18</span>F-FDG&#46; After intravenous administration <span class="elsevierStyleSup">18</span>F-FDG is distributed by the circulatory system and incorporated into tumor cells by the same transport mechanisms as unlabeled glucose&#58; sodium&#8211;glucose transporters and specific membrane transporters or GLUT&#46; Glucose&#44; in the cytoplasm&#44; follows an enzymatic metabolism being phosphorylated by a hexokinase in glucose-6-phosphate&#44; and subsequently by an isomerase is converted to fructose-6-phosphate&#46; After this it can be transformed into glycogen or enter the glycolytic pathway&#46; In the case of <span class="elsevierStyleSup">18</span>F-FDG&#44; incorporating the fluorine atom prevents it from being metabolized after conversion to <span class="elsevierStyleSup">18</span>F-FDG-6-phosphate&#44; consequently having a trapping inside the cell&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Cell entrapment of radiolabeled choline analogs&#46; The choline is introduced into the cell via specific transporters&#44; and once inside it is phosphorylated by the enzyme choline-kinase to yield phosphocholine&#46; This is the first step of the 3 that make up the enzyme cascade known as Kennedy pathway&#44; whose final product is phosphatidylcholine or lecithin&#46; Phosphatidylcholine&#8212;main membrane phospholipid&#8212;is synthesized in 2 steps by means of a reaction catalyzed by phosphocholine citidiltransferase and through phosphocholine transferase&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">73-Year-old patient with newly diagnosed prostate cancer &#40;PSA&#58; 11&#46;95<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#59; Gleason&#58; 4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>5&#59; clinical stage&#58; T3a&#41; under study due to initial staging&#46; <span class="elsevierStyleSup">18</span>F-fluorocholine-PET&#47;CT examination shows in its axial sections of PET &#40;A&#41;&#44; CT &#40;B&#41;&#44; and fusion &#40;F&#41; a focal increase of uptake in the left lobe of the prostate gland &#40;maxSUV&#58; 6&#46;72&#41;&#44; compatible with the neoplastic activity already known at this location&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">75-Year-old patient diagnosed with prostate cancer&#58; PSA 36&#59; Gleason 4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>5&#59; T2b&#46; &#40;1&#41; The axial cuts of the PET&#47;CT with <span class="elsevierStyleSup">18</span>F-fluorocholine show in PET images &#40;1A&#41;&#44; CT &#40;1B&#41; and fusion &#40;1C&#41; significant hyper-uptake &#40;maxSUV 4&#46;62&#41; in both prostatic lobes &#40;empty arrow&#41;&#46; &#40;2&#41; A deposit of the tracer in right internal iliac territory is also observed in the axial projections of the pelic cavity &#40;2A&#8211;2C&#41;&#44; with a maxSUV of 4&#46;18&#44; which corresponds to a small neoplastic aspect adenopathy &#40;solid arrow&#41;&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">64-Year-old patient with a history of prostatectomy 2 years ago&#46; The axial cuts of PET images &#40;A&#41;&#44; CT &#40;B&#41;&#44; and fusion &#40;C&#41; of the study with <span class="elsevierStyleSup">18</span>F-fluorocholine show a hypermetabolic focus &#40;maxSUV 3&#46;29&#41; at right inner para-iliac level &#40;red arrow&#41; coinciding with an unknown adenopathy of metastatic aspect at this location&#46;</p>"
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Article information
ISSN: 21735786
Original language: English
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