Fig. 2.

53-year-old man with a Gleason 4 + 4 PCa pT3 with PSA of 12.5 ng/ml. Primary staging with bone scan showed no lesions suspicious for bone metastases (a), but because he complained of right shoulder pain a ¹⁸F choline PET-CT was performed. This demonstrated focal tracer uptake in the spina scapulae (b, white arrow), indicating a bone metastase. On the corresponding CT image the scapula was unremarkable. Choline PET-CT may demonstrate bone metastases that are occult on bone scan and CT because it can detect changes in the bone marrow before osteoblastic reaction occurs. Nevertheless, bone scan currently remains the standard imaging modality in the primary staging of PCa