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Background  Sodium fluoride (NaF) positron emission tomography combined with computer tomography (PET/CT) has shown to be more sensitive than the whole-body bone scan in the detection of skeletal uptake due to metastases in prostate cancer. We aimed to calculate a 3D index for NaF PET/CT and investigate its correlation to the bone scan index (BSI) and overall survival (OS) in a group of patients with prostate cancer.    Methods  NaF PET/CT and bone scans were studied in 48 patients with prostate cancer. Automated segmentation of the thoracic and lumbar spines, sacrum, pelvis, ribs, scapulae, clavicles, and sternum were made in the CT images. Hotspots in the PET images were selected using both a manual and an automated method. The volume of each hotspot localized in the skeleton in the corresponding CT image was calculated. Two PET/CT indices, based on manual (manual PET index) and automatic segmenting using a threshold of SUV 15 (automated PET 15  index), were calculated by dividing the sum of all hotspot volumes with the volume of all segmented bones. BSI values were obtained using a software for automated calculations.    Results  BSI, manual PET index, and automated PET 15  index were all significantly associated with OS and concordance indices were 0.68, 0.69, and 0.70, respectively. The median BSI was 0.39 and patients with a BSI >0.39 had a significantly shorter median survival time than patients with a BSI <0.39 (2.3 years vs not reached after 5 years of follow-up [ p  = 0.01]). The median manual PET index was 0.53 and patients with a manual PET index >0.53 had a significantly shorter median survival time than patients with a manual PET index <0.53 (2.5 years vs not reached after 5 years of follow-up [ p  < 0.001]). The median automated PET 15  index was 0.11 and patients with an automated PET 15  index >0.11 had a significantly shorter median survival time than patients with an automated PET 15  index <0.11 (2.3 years vs not reached after 5 years of follow-up [ p  < 0.001]).    Conclusions  PET/CT indices based on NaF PET/CT are correlated to BSI and significantly associated with overall survival in patients with prostate cancer.

3D skeletal uptake of 18F sodium fluoride in PET/CT images is associated with overall survival in patients with prostate cancer