Quantitative Assessment of Bone Lesions in Prostate Cancer: Diagnostic Performance of CT Hounsfield Units in Differentiating Metastases From Benign Enostoses

Background: Prostate carcinoma is the third most common malignancy among Malaysian men, and the skeleton is the most frequent metastatic site. Differentiating benign enostoses from osteoblastic metastases on computed tomography (CT) remains challenging. Although 99mTc-MDP bone scintigraphy is the gold standard, capacity constraints often delay treatment. Objectives: To evaluate the diagnostic performance of CT Hounsfield Unit (HU) measurements in differentiating these lesions and their correlation with systemic biological markers. Patients and Methods: We retrospectively evaluated 1041 sclerotic lesions (860 metastases and 181 benign enostoses) from 105 patients with prostate carcinoma. Mean HU values were recorded. Diagnostic metrics were computed at the lesion level, with adjustment for within-patient clustering using Generalized Estimating Equations (GEE). Optimal thresholds were determined using Receiver Operating Characteristic (ROC) analysis. Biological correlations with Gleason scores and Prostate-Specific Antigen (PSA) levels were analyzed using Spearman correlation and validated with GEE. Results: Mean HU demonstrated exceptional discriminatory power (area under the curve [AUC] = 0.984; 95% confidence interval [CI]: 0.975 - 0.993; P < 0.001). The optimal 944.99 HU threshold yielded 90.6% sensitivity, 97.8% specificity, and 99.5% positive predictive value (PPV). After GEE adjustment, histological Gleason grade (P = 0.098), systemic PSA (P = 0.301), and regional density differences (P > 0.05) showed no significant association with lesion density. Conclusion: Quantitative CT attenuation is a highly accurate triage adjunct. In a high-pretest-probability oncological setting, the 944.99 HU threshold confidently rules in benign enostoses, allowing clinicians to safely avoid unnecessary biopsies and optimize nuclear imaging resources.

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