[18F]DCFPyL PET/CT for Imaging of Prostate Cancer

An Automated Deep Learning-Based Framework for Uptake Segmentation and Classification on PSMA PET/CT Imaging of Patients with Prostate Cancer

Uptake segmentation and classification on PSMA PET/CT are important for automating whole-body tumor burden determinations. We developed and evaluated an automated deep learning (DL)-based framework that segments and classifies uptake on PSMA PET/CT. We identified 193 [18F] DCFPyL PET/CT scans of patients with biochemically recurrent prostate cancer from two institutions, including 137 [18F] DCFPyL PET/CT scans for training and internally testing, and 56 scans from another institution for external testing. Two radiologists segmented and labelled foci as suspicious or non-suspicious for malignancy. A DL-based segmentation was developed with two independent CNNs. An anatomical prior guidance was applied to make the DL framework focus on PSMA-avid lesions. Segmentation performance was evaluated by Dice, IoU, precision, and recall. Classification model was constructed with multi-modal decision fusion framework evaluated by accuracy, AUC, F1 score, precision, and recall. Automatic segmentation of suspicious lesions was improved under prior guidance, with mean Dice, IoU, precision, and recall of 0.700, 0.566, 0.809, and 0.660 on the internal test set and 0.680, 0.548, 0.749, and 0.740 on the external test set. Our multi-modal decision fusion framework outperformed single-modal and multi-modal CNNs with accuracy, AUC, F1 score, precision, and recall of 0.764, 0.863, 0.844, 0.841, and 0.847 in distinguishing suspicious and non-suspicious foci on the internal test set and 0.796, 0.851, 0.865, 0.814, and 0.923 on the external test set. DL-based lesion segmentation on PSMA PET is facilitated through our anatomical prior guidance strategy. Our classification framework differentiates suspicious foci from those not suspicious for cancer with good accuracy.

[18F]AlF-PSMA-11 PET in diagnosing prostate cancer: a head-to-head comparison with [68Ga]Ga-PSMA-11 PET and an exploration of dual-phase scanning

PURPOSE

To evaluate the physiological distribution and tumour detection ability of [18F]AlF-PSMA-11 positron emission tomography (PET) dual-phase scans in patients with prostate cancer (PCa).

METHODS

As a retrospective study, clinical and PET data of PCa patients who underwent dual-phase [18F]AlF-PSMA-11 PET of routine scan (45-50 min) and delayed scan (120 min) from November 2020 to June 2021 were collected, and physiological and pathological regions of interest were quantified to determine the time-dependent maximum standardized uptake value (SUVmax) of [18F]AlF-PSMA-11. Part of the above subjects who underwent [68Ga]Ga-PSMA-11 PET in the following 6 months were included in a head-to-head comparison. The difference with a p-value < 0.05 was defined as statistical significance. Diagnosis accuracy of primary and metastatic lesions was measured referring to the surgical findings, pathology, and follow-up imaging.

RESULTS

[68Ga]Ga-PSMA-11 and [18F]AlF-PSMA-11 were of the comparable uptake in glands in head, but the latter was of a significant lower distribution in liver and spleen. For the 25 patients initially diagnosed with prostate cancer and 3 patients with biochemical recurrence after radical surgery, the SUVmax of the primary lesions, lacrimal glands, parotid glands and submandibular glands was higher at 120 min compared to that at 45-50 min, but not a significant difference. SUVmax of the liver, spleen and bladder decreased significantly at 120 min, but the bladder SUVmax remained higher than that of primary lesions. SUVmax of the kidneys and centrum was the same in dual-phase scans. For the 31 primary lesions detected in [18F]AlF-PSMA-11 PET, both the SUVmax of the two phases kept the positive correlation with PSA, Gleason score and initial risk stratification. For the 39 distant metastatic lesions, 94.87% accuracy of routine scan and 100% accuracy of delayed scan were acquired, and 7.14% patients (2/28) benefited from the dual-phase [18F]AlF-PSMA-11 scans that revealed novel information on metastatic lesions compared to the routine scan.

CONCLUSION

[18F]AlF-PSMA-11 PET expanded the time window and further decreased metabolic background of [68Ga]Ga-PSMA-11 PET. The dual-phase scan of [18F]AlF-PSMA-11 PET can benefit prostate cancer diagnosis via providing more PSMA-specific information.

First-in-human study of PSMA-targeting agent, [18F]AlF-P16-093: dosimetry and initial evaluation in prostate cancer patients

PURPOSE

This is a first-in-human study to evaluate the radiation dosimetry of a new prostate-specific membrane antigen (PSMA)-targeted radiopharmaceutical, [18F]AlF-P16-093, and also initial investigation of its ability to detect PSMA-positive tumors using PET scans in a cohort of prostate cancer (PCa) patients.

METHODS

The [18F]AlF-P16-093 was automatically synthesized with a GE TRACERlab. A total of 23 patients with histopathologically proven PCa were prospectively enrolled. Dosimetry and biodistribution study investigations were carried out on a subset of six (6) PCa patients, involving multiple time-point scanning. The mean absorbed doses were estimated with PMOD and OLINDA software.

RESULTS

[18F]AlF-P16-093 was successfully synthesized, and radiochemical purity was > 95%, and average labeling yield was 36.5 ± 8.3% (decay correction, n = 12). The highest tracer uptake was observed in the kidneys, spleen, and liver, contributing to an effective dose of 16.8 ± 1.3 μSv/MBq, which was ~ 30% lower than that of [68Ga]Ga-P16-093. All subjects tolerated the PET examination well, and no reportable side-effects were observed. The PSMA-positive tumors displayed rapid uptake, and they were all detectable within 10 min, and no additional lesions were observed in the following multi-time points scanning. Each patient had at least one detectable tumor lesion, and a total of 356 tumor lesions were observed, including intraprostatic, lymph node metastases, bone metastases, and other soft tissue metastases.

CONCLUSIONS

We report herein a streamlined method for high yield synthesis of [18F]AlF-P16-093. Preliminary study in PCa patients has demonstrated its safety and acceptable radiation dosimetry. The initial diagnostic study indicated that [18F]AlF-P16-093 PET/CT is efficacious and potentially useful for a widespread application in the diagnosis of PCa patients.

Pitfall of 18 F-PSMA PyL PET/CT Imaging of a Displaced Urinary Bladder as Recurrent Prostate Malignancy

ABSTRACT

We herein present a potential pitfall in the setting of restaging PSMA PyL PET/CT. In this case, there is large non-PSMA-avid cystic structure in the mid pelvis, probably representing a postprostatectomy lymphocele, which was mistaken for the urinary bladder, resulting in the displaced and somewhat crescentic urinary bladder to be deemed recurrence. Subsequently, biopsy and retrospective review of images confirms displaced urinary bladder containing physiologic excreted activity.

Pulmonary tumor embolism in renal cell carcinoma detected by hybrid CT and F18-PSMA PET

We present the case of a 75-year-old female in which a pulmonary tumor embolism was detected incidentally on a prostate-specific membrane antigen positron emission tomography-computed tomography restaging scan. This occurred on the background of renal cell carcinoma in remission with pazopanib systemic therapy and a right nephrectomy 4 years prior. An avidity to prostate-specific membrane antigen in the superior lingula of the left upper lobe of the lung coupled with contrast-enhanced computed tomography findings found the lesion to be a tumor thrombus. This case serves to highlight the effectiveness of incorporating contrast-enhanced computed tomography with prostate-specific membrane antigen positron emission tomography and to consider the rare diagnosis of a pulmonary tumor embolism.

Comparison of the Effects of DOTA and NOTA Chelators on 64Cu-Cudotadipep and 64Cu-Cunotadipep for Prostate Cancer

BACKGROUND

This study compared the effects of 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) and 1,4,7-triazacyclononane-1,4,7-triacetic acid (NOTA) as 64Cu-chelating agents in newly developed prostate-specific membrane antigen (PSMA) target compounds, 64Cu-cudotadipep and 64Cu-cunotadipep, on pharmacokinetics.

METHODS

The in vitro stability of the chelators was evaluated using human and mouse serum. In vitro PSMA-binding affinity and cell uptake were compared using human 22Rv1 cells. To evaluate specific PSMA-expressing tumor-targeting efficiency, micro-positron emission tomography (mcroPET)/computed tomography (CT) and biodistribution analysis were performed using PSMA+ PC3-PIP and PSMA- PC3-flu tumor xenografts.

RESULTS

The serum stability of DOTA- or NOTA-conjugated 64Cu-cudotadipep and 64Cu-cunotadipep was >97%. The Ki value of the NOTA derivative, cunotadipep, in the in vitro affinity binding analysis was higher (2.17 ± 0.25 nM) than that of the DOTA derivative, cudotadipep (6.75 ± 0.42 nM). The cunotadipep exhibited a higher cellular uptake (6.02 ± 0.05%/1 × 106 cells) compared with the cudotadipep (2.93 ± 0.06%/1 × 106 cells). In the biodistribution analysis and microPET/CT imaging, the 64Cu-labeled NOTA derivative, 64Cu-cunotadipep, demonstrated a greater tumor uptake and lower liver uptake than the DOTA derivative.

CONCLUSIONS

This study indicates that the PSMA-targeted 64Cu-cunotadipep can be applied in clinical practice owing to its high diagnostic power for prostate cancer.

Highlights on U.S. FDA-approved fluorinated drugs over the past five years (2018-2022)

The objective of this review is to provide an update on the fluorine-containing drugs approved by U.S. Food and Drug Administration in the span of past five years (2018-2022). The agency accepted a total of fifty-eight fluorinated entities to diagnose, mitigate and treat a plethora of diseases. Among them, thirty drugs are for therapy of various types of cancers, twelve for infectious diseases, eleven for CNS disorders, and six for some other diseases. These are categorized and briefly discussed based on their therapeutic areas. In addition, this review gives a glimpse about their trade name, date of approval, active ingredients, company developers, indications, and drug mechanisms. We anticipate that this review may inspire the drug discovery and medicinal chemistry community in both industrial and academic settings to explore the fluorinated molecules leading to the discovery of new drugs in the near future.

Comparative study of 18F-DCFPyL PET/CT and 99mTc-MDP SPECT/CT bone imaging for the detection of bone metastases in prostate cancer

Purpose

This study aimed to compare the diagnostic efficiency of 18F-DCFPyL PET/CT imaging and 99mTc-MDP SPECT/CT bone imaging for the detection of bone metastases in prostate cancer.

Methods

A retrospective analysis was conducted on 31 patients with confirmed prostate cancer between September 2020 and September 2022 at China-Japan Union Hospital of Jilin University. All patients underwent 18F-DCFPyL PET/CT and 99mTc-MDP SPECT/CT bone imaging. The gold standard was the pathology or Best Valuable Comparator (BVC) result based on clinical follow-up. Diagnostic performance indicators, including sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV), were analyzed at both the patient and lesion levels. The paired sample chi-square test was used to compare the two imaging methods. Receiver operating characteristic (ROC) curves were plotted, and the area under the curve (AUC) was calculated for each method. The AUC values were compared using the Z-test, and a p-value < 0.05 was considered statistically significant.

Results

Of the 31 prostate cancer patients, 18 were diagnosed with bone metastases, with a total of 84 bone metastatic lesions. At the patient level, 18F-DCFPyL PET/CT imaging showed superior diagnostic performance compared to 99mTc-MDP SPECT/CT bone imaging in all indicators: sensitivity (100% vs. 77.8%, p < 0.01), specificity (92.3% vs. 69.2%, p < 0.05), accuracy (96.8% vs. 74.2%, p < 0.01), PPV (94.7% vs. 77.8%, p < 0.01), and NPV (100% vs. 69.2%, p < 0.01). The AUC values for 18F-DCFPyL PET/CT imaging and 99mTc-MDP SPECT/CT bone imaging were 0.962 and 0.735 (Z = 2.168, p < 0.05). At the lesion level, 18F-DCFPyL PET/CT imaging showed superior diagnostic performance compared to 99mTc-MDP SPECT/CT bone imaging in all indicators: sensitivity (97.6% vs. 72.6%, p < 0.01), specificity (95.7% vs. 73.9%, p < 0.01), accuracy (97.2% vs. 72.9%, p < 0.01), PPV (98.8% vs. 91.0%, p < 0.01), and NPV (91.7% vs. 42.5%, p < 0.01). The AUC values for 18F-DCFPyL PET/CT imaging and 99mTc-MDP SPECT/CT bone imaging were 0.966 and 0.733 (Z = 3.541, p < 0.001).

Conclusion

Compared with 99mTc-MDP SPECT/CT bone imaging, 18F-DCFPyL PET/CT imaging demonstrated higher diagnostic efficiency for bone metastases in prostate cancer, and it can more accurately determine the presence of bone metastases. It is an important supplement to imaging examination for prostate cancer patients and has great potential and broad application prospects.

Multi-timepoint imaging with PSMA-targeted [18F]F-Florastamin PET/CT: lesion detection and comparison to conventional imaging

OBJECTIVE

The aims of this study were to investigate the utility of [¹⁸F]F-Florastamin, a novel prostate-specific membrane antigen (PSMA)-targeted PET radiotracer with facile radiochemistry, relative to the conventional imaging for the detection of sties of disease and evaluate the effect of multi-timepoint imaging with [¹⁸F]F-Florastamin PET on lesion detectability.

METHODS

Eight prostate cancer patients with known or suspected recurrence who underwent [¹⁸F]F-Florastamin PET/CT at 1-h and 2-h imaging time-points were included in this prospective pilot study. [¹⁸F]F-Florastamin PET images were interpreted visually and quantitatively at both time points and compared with CIM.

RESULTS

[¹⁸F]F-Florastamin PET was superior to CT in the detection of active osseous metastases and small-sized metastatic lymph nodes that do not fall under the anatomic imaging size criteria for metastasis. Multi-timepoint imaging showed a significant reduction in the blood pool, bone marrow and muscular uptake, and increase in liver uptake over time. There is a significant improvement in tumor-to-background ratio (TBR) at the 2-h imaging time-point (P = 0.04). The mean percentage change in TBR at 2-h was 21% (SD = 0.31).

CONCLUSIONS

[¹⁸F]F-Florastamin is a promising new radioligand for PSMA-targeted PET with suitable lesion detectability and high TBR at both time points.

Optimization of Precursor Synthesis Conditions of (2S,4S)4–[18F]FPArg and Its Application in Glioma Imaging

Although the tracer (2S,4S)4–[¹⁸F]FPArg is expected to provide a powerful imaging method for the diagnosis and treatment of clinical tumors, it has not been realized due to the low yield of chemical synthesis and radiolabeling. A simple synthetic method for the radiolabeled precursor of (2S,4S)4–[¹⁸F]FPArg in stable yield was obtained by adjusting the sequence of the synthetic steps. Furthermore, the biodistribution experiments confirmed that (2S,4S)4–[¹⁸F]FPArg could be cleared out quickly in wild type mouse. Cell uptake experiments and U87MG tumor mouse microPET–CT imaging experiments showed that the tumor had high uptake of (2S,4S)4–[¹⁸F]FPArg and the clearance was slow, but (2S,4S)4–[¹⁸F]FPArg was rapidly cleared in normal brain tissue. MicroPET–CT imaging of nude mice bearing orthotopic HS683–Luc showed that (2S,4S)4–[¹⁸F]FPArg can penetrate blood–brain barrier and image gliomas with a high contrast. Therefore, (2S,4S)4–[¹⁸F]FPArg is expected to be further applied in the diagnosis and efficacy evaluation of clinical glioma.