BJR|Open https://doi.org/10.1259/bjro.

20180042

Received: Revised: Accepted:

14 November 2018 07 January 2019 07 January 2019

Cite this article as:

Kawaguchi M, Kato H, Nakano M, Goshima S, Matsuo M. Clinical features of bone metastasis with extraosseous soft-tissue mass in prostate cancer
patients 2019; 1: 20180042.

Original research
Clinical features of bone metastasis with extraosseous
soft-tissue mass in prostate cancer patients
1 1 2 1
Masaya Kawaguchi, MD, Hiroki Kato, MD, Masahiro Nakano, MD, Satoshi Goshima, MD and
1
Masayuki Matsuo, MD
1
Department of Radiology, Gifu University School of Medicine, Gifu, Japan
2
Department of Urology, Gifu University School of Medicine, Gifu, Japan

Address correspondence to: Dr Hiroki Kato

E-mail: hkato@gifu-u.ac.jp

Objective: This study aimed to compare the differences in the
clinical features of prostate cancer (PC) bone metastases
(PCBMs) with and without extraosseous soft-tissue masses
(ESTMs).
Methods: Among 720 consecutive patients with histo-
pathologically or clinically diagnosed PC, PCBMs were
identified in 48 (7%) patients at initial diagnosis before
receiving treatment. CT images of PCBMs were assessed and
classified into two groups: PCBMs with and without ESTMs.
Clinical features of PCBMs with and without ESTMs were
compared.
Results: We found ESTMs in 15 (31%) patients diagnosed
with PCBMs, and 33 (69%) patients diagnosed with PCBMs
did not have ESTMs. The initial prostate-spe-cific antigen
−1
(PSA) levels (median, 1031 vs 247 ng ml ;
p < 0.05) and PSA reduction rates (median, 99.97 vs 99.40 %;
p < 0.05) were significantly greater in PCBMs with ESTMs
than in PCBMs without ESTMs. No signifi-cant differences
were observed in terms of age, Gleason sum score, PSA
nadir, time from the initiation of therapy to PSA nadir, PSA
doubling time, PSA progression-free survival, or overall
survival between patients having PCBMs with and without
ESTMs.
Conclusion: Both initial PSA levels and PSA reduction rates
were higher in PCBMs with ESTMs than in PCBMs without
ESTMs; however, no significant differences were observed in
other clinical features.
Advances in knowledge: ESTMs in patients with PCBMs
were not a poor prognostic factor.

Introduction In PCBMs, although there is a predominant upregulation of

Prostate cancer (PC) is one of the most common malig- osteoblastic activity leading to the formation of miner-alized
1 woven bone, causing the characteristic osteoscle-rotic
nancies in males and a major cause of cancer deaths. The
incidence of PC differs between countries because of the appearance, osteoclasts also play an important part in the
coverage of prostate-specific antigen (PSA) screening; 8
pathophysiology of the metastatic growth process. In a study
however, PC is the cause of 1–2% of male deaths in
popula-tions with and without PSA screening. PC bone of patients with PCBMs who underwent surgery to stabilize a
metastases (PCBMs) occur in approximately 3% of all pathological fracture or impending frac-ture, 39/55 (71%)
2
newly diagnosed patients. In advanced-stage PC, bone is patients with PCBMs had osteoblastic metastases, 9/55 (16%)
the most common site of metastasis, representing >80% of had osteolytic metastases, and the remaining 7/55 (13%) had
2–4 9
all cases. In addi-tion, 17% patients with bone mixed osteolytic and osteo-blastic metastases. Meanwhile,
metastases from unknown primary are associated with we occasionally encounter PCBMs with extraosseous soft-
5 tissue masses (ESTMs). If patients have PCBMs with
PC; thus, PC is closely related to bone metastases.
ESTMs, various manifestations caused by mechanical
Cancer bone metastases are associated with a high risk of compression, such as pain, numb-ness, weakness, and
morbidity. The metastatic spread is primarily located in palpable mass, are clinically observed. However, to our
the skeleton of vertebra and ribs because of dissemination knowledge, no study has assessed the clin-ical significance of
6,7 PCBMs with ESTMs. Thus, this study aimed to reveal the
through the Batson venous plexus. The spread in bone
also follows the distribution of adult red bone marrow, clinical characteristics of PCBMs with ESTMs and compare
such as the skull, thorax, pelvis, spine, and proximal long the differences in the clinical features of PCBMs with and
6 without ESTMs.
bones.
© 2019 The Authors. Published by the British Institute of Radiology under the terms of the Creative Commons Attribution-NonCommercial 4.0 Unported License
http://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted non-commercial reuse, provided the original author and source are credited.
 BJR|Open
Methods and Materials
Patients
The study was approved by the human research committee of our
institutional review board (Gifu University Hospital), and
complied with the guidelines of the Health Insurance Portability
and Accountability Act. The requirement for informed consent was
waived due to the retrospective nature of this study. Between
March 2004 and December 2016, we searched for Gifu University
Hospital’s electronic medical records using registration systems for
diseases and 720 consecutive patients with histopathologi-cally or
clinically diagnosed PC were identified. If histopatho-logical
examinations of the prostate were not performed, high PSA levels
−1
(greater than 100 ng ml ), MRI findings [Category 5 based on
10
prostate imaging reporting and data system (PI-RADS) v. 2], or
histopathological findings of metastatic sites warranted the
diagnosis of PC. Following a whole-body survey for PCBMs using
Tc-99m MDP bone scintigraphy, 18-fludeoxyglucose posi-tron
emission tomography, or whole-body CT scans, PCBMs were
identified in 48 (7%) patients (age range, 55–92 years; mean age,
72 years) at initial diagnosis before receiving treatment.
CT imaging
In all 48 patients with PCBMs, PCBMs were examined using
multidetector-row CT. CT imaging was performed using a 8-slice
CT scanner (LightSpeed Ultra; GE Healthcare, Milwaukee, WI),
16-slice CT scanner (LightSpeed 16; GE Healthcare, Milwaukee,
WI), or a 64-slice CT scanner (Brilliance CT 64; Philips Medical
Systems, Best, Netherlands). Transverse CT images were recon-
structed with 5 mm section thickness and no overlap. Unen-hanced
CT images of PCBMs were reconstructed with bone and soft-tissue
algorithms.
Imaging analysis
Two radiologists (with 18 and 4 years of post-training experi-ence
in musculoskeletal imaging) reviewed all CT images, and any
disagreements were resolved in consensus. After the initial
diagnosis of PC, subsequent CT images of PCBMs were assessed
and classified into two groups: PCBMs with and without ESTMs.
ESTMs referred to bone metastases with extraosseous compo-
nents that grew beyond the bony cortex. ESTMs were continuous
with bone metastases accompanied by intervening preserved or
disrupted the bony cortex. If ESTMs were revealed on CT images,
the reviewers assessed the intraosseous components of the lesions
and categorized the metastases into three groups: osteoblastic,
osteolytic, and mixed osteoblastic and osteolytic. The presence of
calcification in extraosseous components was also assessed. In
patients who underwent repeated CT imaging following hormonal
therapy, the treatment response of extraos-seous components of the
lesions was evaluated.
Clinical findings
In all 48 patients with PCBMs, the clinical data of age, T/N
stage, organ metastases, Gleason sum score, initial clinical
symptoms, treatment methods, sites of PCBMs, initial PSA
–1 –1
level (ng ml ), PSA nadir (ng ml ), PSA reduction rate (%),
time from the initiation of therapy to PSA nadir (day), PSA
doubling time (day), PSA progression-free survival (day), and
overall survival (day) were obtained. PSA nadir was the
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Kawaguchi et al
lowest PSA level during therapy. PSA doubling time was the
time taken for the PSA level to double since PSA nadir and
calculated in patients with a pattern of rising PSA level during
therapy. The PSA reduction rate (%) was calculated as follows:
[(initial PSA–PSA nadir)/initial PSA] × 100. In patients who
had PCBMs with ESTMs, the sites of PCBMs with and without
ESTMs were also recorded.
Statistical analysis
All statistical analyses were performed using SPSS v. 22.0
(SPSS Inc, IBM, Chicago, IL). The Mann–Whitney U test was
used to compare the age, Gleason sum score, initial PSA level,
PSA nadir, PSA reduction rate, time from the initiation of
therapy to PSA nadir, PSA doubling time, and PSA
progression-free survival between patients having PCBMs with
and without ESTMs. Kaplan–Meier curves were used to
estimate overall survival. Null hypotheses of no difference
were rejected if p-values were less than 0.05.
Results
The characteristics of patients diagnosed with PCBMs are
summarized in Table 1. Among the 48 patients diagnosed with
PCBMs, 15 (31%) had PCBMs with ESTMs (age range, 60–90
years; mean age, 71 years) and 33 (69%) had PCBMs without
ESTMs (age range, 55–92 years; mean age, 73 years). In 15
patients who had PCBMs with ESTMs, the coexistence of PCBMs
without ESTMs was found in 10 patients. At the initial diagnosis of
PC, the frequency of patients without symptoms was higher in the
PCBMs without ESTMs group (72%) than in the PCBMs with
ESTMs group (33%), whereas the frequency of patients with
symptoms associated with PCBMs, such as bone pain and nerve
compression symptoms, was higher in the PCBMs with ESTMs
group (47%) than in the PCBMs without ESTMs group (12%). All
48 patients with PCBMs underwent hormonal therapy.
The sites of PCBMs are summarized in Table 2. The most
common site of PCBMs was the pelvic bone in 36 (75%)
patients, followed by the rib in 32 (67%), the lumbosacral spine
in 30 (63%), the thoracic spine in 30 (63%), and the cervical
spine in 16 (33%). Most PCBMs occurred in trunk bones, but
extremity bones were rare occurrence sites.
The characteristics of patients having PCBMs with ESTMs are
summarized in Table 3. Among the 15 patients having PCBMs
with ESTMs, multiple PCBMs with ESTMs were observed in 3
(20%) patients. Before treatment, intraosseous compo-nents of
PCBMs were demonstrated as osteoblastic in 10 (67%)
patients, mixed osteolytic and osteoblastic in 4 (27%), and
osteolytic in 1 (7%), whereas extraosseous components of
PCBMs had no calcification in 9 (60%) patients and had
calcification in 6 (40%) patients. Among the nine patients who
underwent repeated CT imaging following hormonal therapy, it
was observed that extraosseous components of PCBMs
completely disappeared in six (67%) patients, but calcified
extraosseous components remained in three (33%) patients. The
extraosseous components that disappeared after hormonal
therapy were considered ESTMs without calcification before
treatment (Figures 1 and 2), whereas the calcified extraosseous
 Original research: Clinical features of PCBM with ESTM BJR|Open
Table 1. Characteristics of patients diagnosed with PCBMs

Characteristics With ESTMs Without ESTMs Total

Number of patients 15 33 48
Age
Mean 70.7 73.2 72.4
Range 60–90 55–92 55–92
T stage
  2 2(13) 3 (9) 5 (10)
3 8(53) 20 (61) 28 (85)
4 5(33) 10 (30) 15 (31)
N stage
0 6(40) 14 (42) 20 (42)
1 9(60) 19 (58) 28 (58)
Organ metastases
Lung 3(20) 3 (9) 6 (13)
Liver 0 (0) 2 (6) 2 (4)
Adrenal grand 0 (0) 1 (3) 1 (2)
Gleason sum score
6 0 (0) 1 (3) 1 (2)
7 1 (7) 4 (12) 5 (10)
8 1 (7) 5 (15) 6 (13)
9 7(47) 11 (33) 18 (38)
10 0 (0) 2 (6) 2 (4)
Not available 6(40) 10 (30) 16 (33)
Initial symptoms
  Asymptomatic or incidence 5(33) 24 (72) 29 (60)
Urinary symptom 3(20) 5 (15) 8 (17)
  Bone pain caused by PCBMs 4(27) 4 (12) 8 (17)
  - - 3(20) 0 (0) 3 (6)
Nerve compression caused PCB Ms
Hormonal therapy 15(100) 33 (100) 48 (100)
  LH-RH antagonist + FUL/BIC 4(27) 6 (18) 10 (21)
  LH-RH agonist + FUL/BIC 8(53) 23 (70) 31 (65)
LH-RH antagonist 1 (7) 2 (6) 3 (6)
LH-RH agonist 2(13) 2 (6) 4 (8)
Chemotherapy after hormonal therapy 5(33) 9 (27) 14 (29)
Palliative radiation therapy for PCBMs 4(27) 10 (30) 14 (29)
Orthopedic procedure for PCBMs 1 (7) 1 (3) 2 (4)

BIC, bicalutamide; ESTMs, extraosseous soft-tissue masses; FUL, flutamide; PCBMs, prostate cancer bone metastases.
Data are numbers of patients, and numbers in parentheses are frequencies expressed as percentages.

components remaining after hormonal therapy were consid-
ered ESTMs with calcification (Figures 3 and 4).
Quantitative measurements of patients with PCBMs are
summarized in Table 4. Initial PSA levels (median, 1031 vs 247
−1 −1
ng ml ; mean, 3487 ± 5497 vs 651 ± 1075 ng ml ; p =
0.027) and PSA reduction rates (median, 99.97 vs 99.40%;
mean, 98.9 ± 3.0 vs 91.7±27.6%; p = 0.023) were significantly
greater in patients having PCBMs with ESTMs than in those
having PCBMs without ESTMs. No significant differences
were observed in terms of age (median, 69 vs 71 years; mean,
70.3 ± 7.3 vs 73.2 ± 9.0 years; p = 0.321), Gleason sum score

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Table 2. Sites of PCBMs

Sites of PCBMs With ESTMs (n = 15) Without ESTMs (n = 33) Total (n = 48)

Pelvic bone 9 (60) 27 (82) 36 (75)

Rib 9 (60) 23 (70) 32 (67)
Lumbosacral spine 9 (60) 21 (67) 30 (63)
Thoracic spine 8 (53) 22 (67) 30 (63)
Cervical spine 5 (33) 11 (33) 16 (33)
Scapula 5 (33) 6 (18) 11 (23)
Femur 5 (33) 6 (18) 11 (23)
Sternum 2 (13) 7 (21) 9 (19)
Facial bone 3 (20) 5 (15) 8 (15)
Clavicle 3 (20) 4 (12) 7 (5)
Humerus 3 (20) 2 (6) 5 (10)
Skull 3 (20) 2 (6) 5 (10)
Tibia 1 (7) 0 (0) 1 (2)

ESTMs, extraosseous soft-tissue masses; PCBMs, prostate cancer bone metastases.

Data are numbers of patients, and numbers in parentheses are frequencies expressed aspercentages.

(median, 9 vs 9; mean, 8.67 ± 0.71 vs 8.39 ± 1.03; p = 0.471), PSA
−1
nadir (median, 0.152 vs 0.922 ng ml ; mean, 47.0 ± 174.3 vs 70.9
−1
± 263.5 ng ml ; p = 0.225), time from the initiation of therapy to
PSA nadir (median, 167 vs 196 days; mean, 324 ± 336 vs 307 ±
642 days; p = 0.286), PSA doubling time (median, 78 vs 51 days;
mean, 144 ± 163 vs 83 ± 102 days; p = 0.317),
PSA progression- free survival (median, 525 vs 392 days;
mean, 689 ± 453 vs 564 ± 634 days; p = 0.107), and overall
survival (median, 1036 vs 664 days; mean, 1190 ± 938 vs 940 ±
818 days; p = 0.333; Figure 5) between the patients having
PCBMs with and without ESTMs.

Table 3. Characteristics of patients having PCBMs with ESTMs

CT imaging findings of PCBMs with ESTMs

Patients Sites of PCBMs with Sites of PCBMs Extraosseous Extraosseous components
age ESTMs components without ESTMs Intraosseous components after hormonal therapy
1 60 TS S/P/R/O Osteoblastic Without calcification –
2 78 CIivus S/P/R/O Osteoblastic With calcification –
3 69 Rib S/R/O Mixed With calcification Calcified lesion remain
4 68 Sphenoid bone – Mixed With calcification –
5 66 Rib – Osteoblastic Without calcification Disappear
6 66 Scapula – Osteoblastic Without calcification Disappear
7 76 Rib S/P/R/O Osteoblastic Without calcification Disappear
8 69 Rib S/P Osteoblastic With calcification Calcified lesion remain
9 76 TS S/R Osteolytic Without calcification Disappear
10 75 Pubis S/P Osteoblastic Without calcification Disappear
11 68 Pelvic bone, femur S/P/O Mixed With calcification Calcified lesion remain
12 63 LS S/P/R/O Osteoblastic Without calcification Disappear
13 90 Coccygeal bone – Osteoblastic Without calcification –
14 69 Tibia – Mixed Without calcification –
15 68 Scapula S/R/P/O Osteoblastic With calcification –

ESTMs, extraosseous soft-tissue masses; LV, lumber spine; O, other bone; P, pelvic bone; PCBMs, prostate cancer bone metastases; R, rib; S, spine; TS, thoracic
spine; mixed, mixed osteolytic and osteoblastic.

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 Original research: Clinical features of PCBM with ESTM
Figure 1. A 76-year-old male having PCBMs with ESTMs (Patient 9). (a) CT image before hormonal therapy shows osteolytic bone metastasis
(arrows) and extraosseous components without calcification (arrow heads) in seventh thoracic spine. (b) CT image after hormonal therapy for 2
months shows decreased osteolytic bone metastasis (arrows) and disappeared extraosseous compo-nents. ESTM, extraosseous soft-tissue
mass; PCBMs, prostate cancer bone metastases.
Discussion
A previous study on 248 patients initially diagnosed with
−1
PCBMs reported that the initial PSA level was <20 ng ml in
−1
39 (15.7%) patients, 20–100 ng ml in 89 (35.9%), 100–1000
−1 −1
ng ml in 90 (36.3%), and 1000–10,000 ng ml in 30
2
(12.1%). In contrast, our cohort study showed higher PSA
levels. The exposure rate of screening for PC using PSA in
Japan is still very low compared with that in USA or western
Europe; hence, many clinically significant cancer cases in
Japan might be undetected and missed until they develop to
clinically advanced stages of the disease.
11,12
Therefore, we
estimated that many advanced PC patients were included in our
Japanese cohort. In fact, 11/48 (23%) patients with PCBMs in
our study were diagnosed with PC triggered by the initial
symptoms associated with PCBMs.
Figure 2. A 60-year-old male having PCBMs with ESTMs (Patient 1).
(a) CT image before hormonal therapy shows oste-oblastic bone
metastasis (arrows) and extraosseous compo-nents without
th
calcification (arrow heads) in 11 thoracic spine.
(b) H&E stain shows extraosseous components of bone metas-tasis
(asterisk) adjacent to the surrounding adipose tissue (star). ESTM,
extraosseous soft-tissue mass; H&E, hematoxylin and eosin;
PCBMs, prostate cancer bone metastases.
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Previous studies have described bone metastases with ESTMs
from various primary cancers. Mizumoto et al reported that
111/603 (18%) patients with spinal bone metastases from lung,
breast, gastrointestinal, prostate, and liver cancer, among
others, showed mass-type tumors; however, the frequency of
mass-type tumor in each cancer was not shown. An et al
13
reported that 39/169 (23%) spinal metastatic lesions from lung,
breast, colorectal, hepatocellular, and stomach cancer (71% in
hepato-cellular carcinoma, 55% in colorectal cancer, 23% in
lung cancer, 7% in breast cancer, and 2% in stomach cancer) in
14
30 patients showed extraosseous invasion. In this study,
metastatic bone lesions of hepatocellular carcinoma and
colorectal cancer showed a tendency to have ESTMs, whereas
those of breast cancer, which typically show osteoblastic
14
metastases, were less likely to have ESTMs.
Figure 3. A 68-year-old male having PCBMs with ESTMs (Patient
11). (a) CT image before hormonal therapy shows mixed
osteoblastic and osteolytic bone metastasis (arrows) and
extraosseous components with calcification (arrow heads) in pelvic
bone. (b) CT image after hormonal therapy for eight months shows
remaining calcified extraosseous components (arrows). ESTM,
extraosseous soft-tissue mass; PCBMs, prostate cancer bone
metastases.
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 BJR|Open Kawaguchi et al

Figure 4. A 68-year-old male having PCBMs with ESTMs (Patient 4).
(a) CT image before hormonal therapy shows mixed osteoblastic
and osteolytic bone metastasis (arrow) and extraosseous
components with calcification (arrow heads) in sphenoid bone. (b)
H&E stain shows extraosseous components of bone metastasis
(asterisk) with fragmented the bony cortex (star). ESTM,
extraosseous soft-tissue mass; H&E, hematoxylin and eosin;
PCBMs, prostate cancer bone metastases.
a considerable difference in the frequency of PCBMs with
ESTMs between the two studies might be observed.
Yucei et al also assessed the prognosis of bone metastases with
15
a tumor mass. Although they concluded that bone metas-tasis
with a tumor mass was a strong and independent factor for
survival in cancer patients, results specific to PC were not
15
provided. However, no significant differences were observed
in our study with respect to prognostic factors, such as PSA
progression-free survival and overall survival, between patients
having PCBMs with and without ESTMs. Similarly, a study of
bone metastases from hepatocellular carcinoma treated by
external beam radiotherapy also showed no significant
difference in the survival rate of patients having bone
16
metastases with and without soft-tissue extension. Thus,
further investigation is still required to determine whether
ESTMs of PCBMs is a poor prog-nostic factor or not.

Patients diagnosed with PCBMs with ESTMs were charac-

Yucei et al reported that 73/335 (22%) patients with bone
metastases (107 patients with lung cancer, 64 with breast cancer,
15
62 with PC, and 102 with others types) showed a tumor mass.
15
Among them, 4/62 (6%) patients with PC showed a tumor mass.
Although the term “tumor mass” in the previous study would have
a similar meaning to ESTMs in our study, the frequency of PCBMs
15
with ESTMs was considerably lower in the previous study (6%)
than in our study (31%). Because the detailed definition and
detection modality of a tumor mass was not provided in the
previous study, the presence of ESTMs might not have been
detected accurately. On the other hand, radiologists carefully
evaluated the presence of ESTMs using CT images in our study. In
addition, our Japanese cohort had the potential to include many
advanced PC patients. Thus,
terized by initial symptoms associated with ESTMs, such as
bone pain and nerve compression symptoms. In our study,
ESTMs without calcification tended to disappear after
hormonal therapy, whereas those with calcification tended to
remain as calcified extraosseous components even after
hormonal therapy. Therefore, because mechanical compres-sion
symptoms may not improve in ESTMs with calcification
treated by hormonal therapy, initial surgical procedures may be
considered if ESTMs with calcification are symptomatic. In
addition, Vestergaard et al reported that the frequency of the
risk of fracture in patients with PC increased with time, and the
17
main increase in risk was seen in the first year because
18
patients with PC develop osteoporosis by hormone therapy.
Therefore, the risk of fracture should be care-fully monitored
during hormonal therapy in patients with PCBMs.

Table 4. Quantitative measurements of patients with PCBMs

PCBMs with ESTMs PCBMs without ESTMs p-value

Number 15 33
Age 69 (60–90) 71 (55–92) 0.321

Gleason sum score 9 (7–9) 9 (6–10) 0.471

–1
Initial PSA level (ng ml ) 1031 (20.5–16700) 247 (20.3–5383) 0.027
a

–1 0.152 (0.001–677) 0.922 (0.001–11.63) 0.225

PSA nadir (ng ml )
PSA reduction rate (%) 99.97 (88.70–100.00) 99.40 (64.07–100.00) 0.023
a

Time to PSA nadir (day) 167 (104–1383) 196 (44–3829) 0.286

PSA doubling time (day) 78 (23–455) 51 (16–457) 0.317
PSA PFS (day) 525 (104–1474) 392 (33–2461) 0.107
OS (days) 1036 (129–3245) 664 (72–3338) 0.333

ESTMs, extraosseous soft-tissuemasses; OS, overall survival; PCBMs, prostate cancer bone metastases; PFS, progression free survival; PSA, prostate-specific
antigen; PSA doubling time, time taken for the PSA level to double sincePSA nadir; Time to PSA nadir, time from the initiation oftherapy to PSA nadir.

Data are age, Gleason sum score, initial PSA level, PSA nadir, PSA reduction rate, time to PSA nadir, PSA doubling time, PSA PFS, and OS, with median.
Numbers in parentheses are range of numbers
a
The values of PCBMs with ESTMs were significant higher than those of PCBMs without ESTM (p < 0.05).

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 Original research: Clinical features of PCBM with ESTM BJR|Open

Figure 5. Kaplan–Meier survival curve for overall survival. No significant differences were observed in overall survival between PCBMs with and
without ESTMs (median, 1036 vs 664 days; mean, 1190 ± 938 vs 940 ± 818 days; p = 0.333). ESTM, extraosseous soft-tissue mass; PCBMs,
prostate cancer bone metastases.

This study had several limitations. First, the cohort was relatively
small because the study was conducted at a single institution.
Second, prostate biopsy was not performed in 15 (31%) of 48
patients in this study. Because biopsy confirmation should be the
most important criteria for diagnosis of PC, this may compli-cate
the comparison of the results obtained in the future by other lines
of research. However, among 15 patients who did not undergo
histopathological examinations of the prostate in our study,
−1
extremely elevated PSA levels (greater than 100 ng ml ) alone
were observed in 9 patients, combination of extremely elevated
−1
PSA levels (greater than 100 ng ml ) and MR findings of
Category 5 based on PI-RADS v. 2 in 3, histopathological
confirmations of metastatic sites in 2 patients, and MR findings of
Category 5 based on PI-RADS v. 2 alone in the remaining 1
−1
patient. The reason for the PSA cutoff of 100 ng ml was that a
serum PSA level higher than 100 ng ml
−1
was 100% accurate
19
in predicting the presence of prostate cancer on tissue biopsy.
Therefore, we believe that these clinical and radiological
findings warrant the diagnosis of PC.
Conclusion
In conclusion, CT images revealed that PCBMs with ESTMs
were not uncommon. PCBMs with ESTMs commonly occurred
in the spine, pelvic bone, and ribs, as did PCBMs without
ESTMs. PCBMs with ESTMs had a tendency to have both high
initial PSA levels and high PSA reduction rates; hence,
hormonal therapy would be effective for PCBMs with ESTMs.
Thus, PCBMs with ESTMs were not a poor prognostic factor.
ESTMs without calcification tended to disappear after
hormonal therapy, whereas ESTMs with calcification tended to
remain as calcified extraosseous components.

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