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Lawal IO, Jani AB, Adediran OA, Goyal S, Abiodun-Ojo OA, Dhere VR, Marcus CV, Joshi SS, Master VA, Patel PR, Goodman M, Shelton JW, Kucuk O, Hershatter B, Fielder B, Halkar RK, Schuster DM. Differences in Failure-Free Survival After Salvage Radiotherapy Guided by Conventional Imaging Versus 18F-Fluciclovine PET/CT in Postprostatectomy Patients: A Post Hoc Substratification Analysis of the EMPIRE-1 Trial. J Nucl Med 2023; 64:586-591. [PMID: 36328489 PMCID: PMC10071787 DOI: 10.2967/jnumed.122.264832] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022] Open
Abstract
The EMPIRE-1 (Emory Molecular Prostate Imaging for Radiotherapy Enhancement 1) trial reported a survival advantage in recurrent prostate cancer salvage radiotherapy (SRT) guided by 18F-fluciclovine PET/CT versus conventional imaging. We performed a post hoc analysis of the EMPIRE-1 cohort stratified by protocol-specified criteria, comparing failure-free survival (FFS) between study arms. Methods: EMPIRE-1 randomized patients to SRT planning via either conventional imaging only (bone scanning plus abdominopelvic CT or MRI) (arm A) or conventional imaging plus 18F-fluciclovine PET/CT (arm B). Randomization was stratified by prostate-specific antigen (PSA) level (<2.0 vs. ≥ 2.0 ng/mL), adverse pathology, and androgen-deprivation therapy (ADT) intent. We subdivided patients in each arm using the randomization stratification criteria and compared FFS between patient subgroups across study arms. Results: Eighty-one and 76 patients received per-protocol SRT in study arms A and B, respectively. The median follow-up was 3.5 y (95% CI, 3.0-4.0). FFS was 63.0% and 51.2% at 36 and 48 mo, respectively, in arm A and 75.5% at both 36 and 48 mo in arm B. Among patients with a PSA of less than 2 ng/mL (mean, 0.42 ± 0.42 ng/mL), significantly higher FFS was seen in arm B than arm A at 36 mo (83.2% [95% CI, 70.0-91.0] vs. 66.5% [95% CI, 51.6-77.8], P < 0.001) and 48 mo (83.2% [95% CI, 70.0-91.0] vs. 56.2% [95% CI, 40.5-69.2], P < 0.001). No significant difference in FFS between study arms in patients with a PSA of at least 2 ng/mL was observed. Among patients with adverse pathology, significantly higher FFS was seen in arm B than arm A at 48 mo (68.9% [95% CI, 52.1-80.8] vs. 42.8% [95% CI, 26.2-58.3], P < 0.001) though not at the 36-mo follow-up. FFS was higher in patients without adverse pathology in arm B versus arm A (90.2% [95% CI, 65.9-97.5] vs. 73.1% [95% CI, 42.9-89.0], P = 0.006) at both 36 and 48 mo. Patients in whom ADT was intended in arm B had higher FFS than those in arm A, with the difference reaching statistical significance at 48 mo (65.2% [95% CI, 40.3-81.7] vs. 29.1 [95% CI, 6.5-57.2], P < 0.001). Patients without ADT intent in arm B had significantly higher FFS than patients in arm A at 36 mo (80.7% [95% CI, 64.9-90.0] vs. 68.0% [95% CI, 51.1-80.2]) and 48 mo (80.7% [95% CI, 64.9-90.0] vs. 58.6% [95% CI, 41.0-72.6]). Conclusion: The survival advantage due to the addition of 18F-fluciclovine PET/CT to SRT planning is maintained regardless of the presence of adverse pathology or ADT intent. Including 18F-fluciclovine PET/CT to SRT leads to survival benefits in patients with a PSA of less than 2 ng/mL but not in patients with a PSA of 2 ng/mL or higher.
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Affiliation(s)
- Ismaheel O Lawal
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia;
- Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa
| | - Ashesh B Jani
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Omotayo A Adediran
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Subir Goyal
- Biostatics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | | | - Vishal R Dhere
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Charles V Marcus
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Shreyas S Joshi
- Department of Urology, Emory University, Atlanta, Georgia; and
| | - Viraj A Master
- Department of Urology, Emory University, Atlanta, Georgia; and
| | - Pretesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Mark Goodman
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Joseph W Shelton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Omer Kucuk
- Department of Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Bruce Hershatter
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Bridget Fielder
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Raghuveer K Halkar
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - David M Schuster
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
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Solanki AA, Puckett LL, Kujundzic K, Katsoulakis E, Park J, Kapoor R, Hagan M, Kelly M, Palta J, Ballas LK, DeMarco J, Hoffman KE, Lawton CAF, Michalski J, Potters L, Zelefsky M, Kudner R, Dawes S, Wilson E, Sandler H. Consensus Quality Measures and Dose Constraints for Prostate Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Expert Panel. Pract Radiat Oncol 2023; 13:e149-e165. [PMID: 36522277 DOI: 10.1016/j.prro.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/15/2022] [Accepted: 08/26/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE There are no agreed upon measures to comprehensively determine the quality of radiation oncology (RO) care delivered for prostate cancer. Consequently, it is difficult to assess the implementation of scientific advances and adherence to best practices in routine clinical practice. To address this need, the US Department of Veterans Affairs (VA) National Radiation Oncology Program established the VA Radiation Oncology Quality Surveillance (VA ROQS) Program to develop clinical quality measures to assess the quality of RO care delivered to Veterans with cancer. This article reports the prostate cancer consensus measures. METHODS AND MATERIALS The VA ROQS Program contracted with the American Society for Radiation Oncology to commission a Blue Ribbon Panel of prostate cancer experts to develop a set of evidence-based measures and performance expectations. From February to June 2021, the panel developed quality, aspirational, and surveillance measures for (1) initial consultation and workup, (2) simulation, treatment planning, and delivery, and (3) follow-up. Dose-volume histogram (DVH) constraints to be used as quality measures for definitive and post-prostatectomy radiation therapy were selected. The panel also identified the optimal Common Terminology Criteria for Adverse Events, version 5.0 (CTCAE V5.0), toxicity terms to assess in follow-up. RESULTS Eighteen prostate-specific measures were developed (13 quality, 2 aspirational, and 3 surveillance). DVH metrics tailored to conventional, moderately hypofractionated, and ultrahypofractionated regimens were identified. Decision trees to determine performance for each measure were developed. Eighteen CTCAE V5.0 terms were selected in the sexual, urinary, and gastrointestinal domains as highest priority for assessment during follow-up. CONCLUSIONS This set of measures and DVH constraints serves as a tool for assessing the comprehensive quality of RO care for prostate cancer. These measures will be used for ongoing quality surveillance and improvement among veterans receiving care across VA and community sites. These measures can also be applied to clinical settings outside of those serving veterans.
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Affiliation(s)
- Abhishek A Solanki
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, Illinois; Department of Radiation Oncology, Edward Hines Jr, VA Hospital, Hines, Illinois.
| | - Lindsay L Puckett
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
| | | | - Evangelia Katsoulakis
- Department of Radiation Oncology, James A. Haley Veterans Affairs Healthcare System, Tampa, Florida
| | - John Park
- Department of Radiation Oncology, Kansas City VA Medical Center, Kansas City, Missouri; Department of Radiation Oncology, University of Missouri, Kansas City, Missouri
| | - Rishabh Kapoor
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Michael Hagan
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia; National Radiation Oncology Program, Veteran's Healthcare Administration, Richmond, Virginia
| | - Maria Kelly
- National Radiation Oncology Program, Veteran's Healthcare Administration, Richmond, Virginia
| | - Jatinder Palta
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia; National Radiation Oncology Program, Veteran's Healthcare Administration, Richmond, Virginia
| | - Leslie K Ballas
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - John DeMarco
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen E Hoffman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Colleen A F Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri
| | - Louis Potters
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, New York; Department of Radiation Medicine, Zucker School of Medicine, Hempstead, New York
| | - Michael Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Randi Kudner
- American Society for Radiation Oncology, Arlington, Virginia
| | - Samantha Dawes
- American Society for Radiation Oncology, Arlington, Virginia
| | - Emily Wilson
- American Society for Radiation Oncology, Arlington, Virginia
| | - Howard Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
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Payne H, Bomanji J, Bottomley D, Scarsbrook AF, Teoh EJ. Impact of 18F-fluciclovine PET/CT on salvage radiotherapy plans for men with recurrence of prostate cancer postradical prostatectomy. Nucl Med Commun 2022; 43:201-211. [PMID: 34669678 PMCID: PMC8754096 DOI: 10.1097/mnm.0000000000001501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/04/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Imaging options to localize biochemical recurrence (BCR) of prostate cancer after radical prostatectomy (RP) are limited, especially at low prostate-specific antigen (PSA) levels. The FALCON study evaluated the impact of 18F-fluciclovine PET/CT on management plans for patients with BCR. Here, we evaluate salvage radiotherapy decisions in patients post-RP. METHODS We conducted a subgroup analysis of post-RP patients enrolled in FALCON who had a prescan plan for salvage radiotherapy (± androgen-deprivation therapy). Patients' treatment plans post-18F-fluciclovine PET/CT were compared with their prescan plans. Fisher exact test was used to determine the impact of PSA and Gleason sum on positivity and anatomical patterns of uptake. RESULTS Sixty-five (63%) FALCON patients had undergone RP. Of these, 62 (median PSA, 0.32 ng/mL) had a prescan plan for salvage radiotherapy. Twenty-one (34%) had 18F-fluciclovine-avid lesions. Disease was confined to the prostate bed in 11 patients (52%) and to the pelvis in a further 5 (24%), while 5 (24%) had extrapelvic findings. Trends towards more disseminated disease with increasing PSA or Gleason sum were observed but did not reach statistical significance. Postscan, 25 (40%) patients had a management change; 17 (68%) were changed to the treatment modality (8 to systemic therapy, 8 to active surveillance, 1 other) and 8 (32%) were radiotherapy field modifications. CONCLUSIONS Incorporating 18F-fluciclovine PET/CT into treatment planning may help identify patients suitable for salvage radiotherapy, help augment planned radiotherapy to better target lesions and support the clinician to optimise patient management.
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Affiliation(s)
- Heather Payne
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London
| | - Jamshed Bomanji
- Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London
| | | | | | - Eugene J. Teoh
- Departments of Radiology and Nuclear Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK (at the time of study conduct)
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4
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Ong JS, Hofman MS. PET imaging of prostate cancer. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00111-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Rais-Bahrami S, Efstathiou JA, Turnbull CM, Camper SB, Kenwright A, Schuster DM, Scarsbrook AF. 18F-Fluciclovine PET/CT performance in biochemical recurrence of prostate cancer: a systematic review. Prostate Cancer Prostatic Dis 2021; 24:997-1006. [PMID: 34012062 PMCID: PMC8616758 DOI: 10.1038/s41391-021-00382-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/13/2021] [Accepted: 04/28/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND A systematic literature review of the performance of 18Fluorine-fluciclovine PET/CT for imaging of men with recurrent prostate cancer was performed. METHODS Scientific literature databases (MEDLINE, ScienceDirect and Cochrane Libraries) were searched systematically during Oct 2020 using PRISMA criteria. No limit was put on the date of publication. Prospective studies reporting a patient-level 18F-fluciclovine detection rate (DR) from ≥25 patients with recurrent prostate cancer were sought. Proceedings of relevant meetings held from 2018 through Oct 2020 were searched for abstracts meeting criteria. RESULTS Searches identified 321 unique articles. In total, nine articles (six papers and three conference abstracts), comprising a total of 850 patients met inclusion criteria. Most studies (n = 6) relied on ASTRO-Phoenix Criteria, EAU-ESTRO-SIOG, and/or ASTRO-AUA guidelines to identify patients with biochemical recurrence. Patients' PSA levels ranged from 0.02-301.7 ng/mL (median level per study, 0.34-4.10 ng/mL [n = 8]). Approximately 64% of patients had undergone prostatectomy, but three studies focused solely on post-prostatectomy patients. Adherence to imaging protocol guidelines was heterogeneous, with variance seen in administered activity, uptake and scan times. Overall patient-level DR varied between studies from 26% to 83%, with 78% of studies reporting a DR > 50%. DR was proportional to PSA, but even at PSA < 0.5 ng/mL DR of up to 53% were reported. Prostate/bed DR (n = 7) ranged from 18% to 78% and extra-prostatic rates (n = 6) from 8% to 72%. Pelvic node and bone lesion DR ranged from 8% to 47% and 0% to 26%, respectively (n = 5). 18F-Fluciclovine PET/CT was shown to impact patient management and outcomes. Two studies reported 59-63% of patients to have a management change post-scan. A further study showed significant increase in failure-free survival following 18F-fluciclovine-guided compared with conventional imaging-guided radiotherapy planning. CONCLUSIONS 18F-Fluciclovine PET/CT shows good performance in patients with recurrent prostate cancer leading to measurable clinical benefits. Careful adherence to recommended imaging protocols may help optimize DR.
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Affiliation(s)
- Soroush Rais-Bahrami
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | - David M Schuster
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Andrew F Scarsbrook
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
- Leeds Institute of Health Research, University of Leeds, Leeds, UK.
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Abiodun-Ojo OA, Jani AB, Akintayo AA, Akin-Akintayo OO, Odewole OA, Tade FI, Joshi SS, Master VA, Fielder B, Halkar RK, Zhang C, Goyal S, Goodman MM, Schuster DM. Salvage Radiotherapy Management Decisions in Postprostatectomy Patients with Recurrent Prostate Cancer Based on 18F-Fluciclovine PET/CT Guidance. J Nucl Med 2021; 62:1089-1096. [PMID: 33517323 PMCID: PMC8833876 DOI: 10.2967/jnumed.120.256784] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/14/2020] [Indexed: 11/16/2022] Open
Abstract
Imaging with novel PET radiotracers has significantly influenced radiotherapy decision making and radiation planning in patients with recurrent prostate cancer (PCa). The purpose of this analysis was to report the final results for management decision changes based on 18F-fluciclovine PET/CT findings and determine whether the decision change trend remained after completion of accrual. Methods: Patients with detectable prostate-specific antigen (PSA) after prostatectomy were randomized to undergo either conventional imaging (CI) only (arm A) or CI plus 18F-fluciclovine PET/CT (arm B) before radiotherapy. In arm B, positivity rates on CI and 18F-fluciclovine PET/CT for detection of recurrent PCa were determined. Final decisions on whether to offer radiotherapy and whether to include only the prostate bed or also the pelvis in the radiotherapy field were based on 18F-fluciclovine PET/CT findings. Radiotherapy decisions before and after 18F-fluciclovine PET/CT were compared. The statistical significance of decision changes was determined using the Clopper-Pearson (exact) binomial method. Prognostic factors were compared between patients with and without decision changes. Results: All 165 patients enrolled in the study had standard-of-care CI and were initially planned to receive radiotherapy. Sixty-three of 79 (79.7%) patients (median PSA, 0.33 ng/mL) who underwent 18F-fluciclovine PET/CT (arm B) had positive findings. 18F-Fluciclovine PET/CT had a significantly higher positivity rate than CI did for the whole body (79.7% vs. 13.9%; P < 0.001), prostate bed (69.6% vs. 5.1%; P < 0.001), and pelvic lymph nodes (38.0% vs. 10.1%; P < 0.001). Twenty-eight of 79 (35.4%) patients had the overall radiotherapy decision changed after 18F-fluciclovine PET/CT; in 4 of 79 (5.1%), the decision to use radiotherapy was withdrawn because of extrapelvic disease detected on 18F-fluciclovine PET/CT. In 24 of 75 (32.0%) patients with a final decision to undergo radiotherapy, the radiotherapy field was changed. Changes in overall radiotherapy decisions and radiotherapy fields were statistically significant (P < 0.001). Overall, the mean PSA at PET was significantly different between patients with and without radiotherapy decision changes (P = 0.033). Conclusion:18F-Fluciclovine PET/CT significantly altered salvage radiotherapy decisions in patients with recurrent PCa after prostatectomy. Further analysis to determine the impact of 18F-fluciclovine PET/CT guidance on clinical outcomes after radiotherapy is in progress.
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Affiliation(s)
| | - Ashesh B Jani
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Akinyemi A Akintayo
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | | | - Oluwaseun A Odewole
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Funmilayo I Tade
- Department of Radiology, Loyola University Medical Center, Maywood, Illinois
| | | | - Viraj A Master
- Department of Urology, Emory University, Atlanta, Georgia
| | - Bridget Fielder
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Raghuveer K Halkar
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Chao Zhang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Subir Goyal
- Department of Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia; and
| | - Mark M Goodman
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
- Emory University Center for Systems Imaging, Atlanta, Georgia
| | - David M Schuster
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
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A bicentric retrospective analysis of clinical utility of 18F-fluciclovine PET in biochemically recurrent prostate cancer following primary radiation therapy: is it helpful in patients with a PSA rise less than the Phoenix criteria? Eur J Nucl Med Mol Imaging 2021; 48:4463-4471. [PMID: 34091713 DOI: 10.1007/s00259-021-05415-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE 18F-Fluciclovine PET imaging has been increasingly used in the restaging of prostate cancer patients with biochemical recurrence (BCR); however, its clinical utility in patients with low prostate-specific antigen (PSA) levels following primary radiation therapy has not been well-studied. This study aims to determine the detection rate and diagnostic accuracy of 18F-fluciclovine PET and the patterns of prostate cancer recurrence in patients with rising PSA after initial radiation therapy, particularly in patients with PSA levels below the accepted Phoenix definition of BCR (PSA nadir +2 ng/mL). METHODS This retrospective study included patients from two tertiary institutions who underwent 18F-fluciclovine PET scans for elevated PSA level following initial external beam radiation therapy, brachytherapy, and/or proton therapy. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed to determine the diagnostic accuracy of 18F-fluciclovine PET and associations of PSA kinetic parameters with 18F-fluciclovine PET outcome. RESULTS One hundred patients were included in this study. The overall detection rate on a patient-level was 79% (79/100). 18F-Fluciclovine PET was positive in 62% (23/37) of cases with PSA below the Phoenix criteria. The positive predictive value of 18F-fluciclovine PET was 89% (95% CI: 80-94%). In patients with PSA below the Phoenix criteria, the PSA velocity had the highest predictive value of 18F-fluciclovine PET outcome. PSA doubling time (PSADT) and PSA velocity were associated with the presence of extra-pelvic metastatic disease. CONCLUSION 18F-Fluciclovine PET can identify recurrent disease at low PSA level and PSA rise below accepted Phoenix criteria in patients with suspected BCR after primary radiation therapy, particularly in patients with low PSADT or high PSA velocity. In patients with low PSADT or high PSA velocity, there is an increased probability of extra-pelvic metastases. Therefore, these patients are more likely to benefit from PET/CT or PET/MRI than pelvic MRI alone.
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Role of 18F-Fluciclovine and Prostate-Specific Membrane Antigen PET/CT in Guiding Management of Oligometastatic Prostate Cancer: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 216:851-859. [PMID: 33206564 DOI: 10.2214/ajr.20.24711] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Twenty-five years ago, oligometastatic disease was proposed as an intermediary clinical state of cancer with unique implications for therapies that may impact cancer evolution and patient outcome. Identification of limited metastases that are potentially amenable to targeted therapies fundamentally depends on the sensitivity of diagnostic tools, including new-generation imaging methods. For men with biochemical recurrence after definitive therapy of the primary prostate cancer, PET/CT using either the FDA-approved radiolabeled amino acid analogue 18F-fluciclovine or investigational radiolabeled agents targeting prostate-specific membrane antigen (PSMA) enables identification of early metastases at lower serum PSA levels than was previously feasible using conventional imaging. Evidence supports PSMA PET/CT as the most sensitive imaging modality available for identifying disease sites in oligometastatic prostate cancer. PSMA PET/CT will likely become the modality of choice after regulatory approval and will drive the development of trials of emerging metastasis-directed therapies such as stereotactic ablative body radiation and radioguided surgery. Indeed, numerous ongoing or planned clinical trials are studying advances in management of oligometastatic prostate cancer based on this heightened diagnostic capacity. In this rapidly evolving clinical environment, radiologists and nuclear medicine physicians will play major roles in facilitating clinical decision making and management of patients with oligometastatic prostate cancer.
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