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Fodor A, Brombin C, Deantoni CL, Giannini L, Ferrario F, Villa SL, Mangili P, Rancoita PMV, Cozzarini C, Picchio M, Del Vecchio A, Fiorino C, Di Serio MCS, Chiti A, Di Muzio NG. Extended nodal radiotherapy for prostate cancer relapse guided with [11C]-choline PET/CT: ten-year results in patients enrolled in a prospective trial. Eur J Nucl Med Mol Imaging 2024; 51:590-603. [PMID: 37747578 DOI: 10.1007/s00259-023-06445-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 09/15/2023] [Indexed: 09/26/2023]
Abstract
AIMS To report long-term outcomes of relapsed prostate cancer (PC) patients treated in a prospective single-arm study with extended-nodal radiotherapy (ENRT) and [11C]-choline positron emission tomography (PET)/computed tomography (CT)-guided simultaneous integrated boost (SIB) to positive lymph nodes (LNs). METHODS From 12/2009 to 04/2015, 60 PC patients with biochemical relapse and positive LNs only were treated in this study. ENRT at a median total dose (TD) = 51.8 Gy/28 fr and PET/CT-guided SIB to positive LNs at a median TD = 65.5 Gy was prescribed. Median PSA at relapse was 2.3 (interquartile range, IQR:1.3-4.0) ng/ml. Median number of positive LNs: 2 (range: 1-18). Androgen deprivation therapy (ADT) was prescribed for 48 patients for a median of 30.7 (IQR: 18.5-43.1) months. RESULTS Median follow-up from the end of salvage treatment was 121.8 (IQR: 116.1, 130.9) months; 3-, 5-, and 10-year BRFS were 45.0%, 36.0%, and 24.0%, respectively; DMFS: 67.9%, 57.2%, and 45.2%; CRFS: 62.9%, 53.9%, and 42.0%; and OS: 88.2%, 76.3%, and 47.9%, respectively. Castration resistance (p < 0.0001) and ≥ 6 positive LN (p = 0.0024) significantly influenced OS at multivariate analysis. Castration resistance (p < 0.0001 for both) influenced DMFS and CRFS in multivariate analysis. CONCLUSIONS In PC relapsed patients treated with ENRT and [11C]-choline-PET/CT-guided SIB for positive LNs, with 10-year follow-up, a median Kaplan-Meier estimate CRFS of 67 months and OS of 110 months were obtained. These highly favorable results should be confirmed in a prospective, randomized trial.
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Affiliation(s)
- A Fodor
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - C Brombin
- University Center for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - C L Deantoni
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - L Giannini
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - F Ferrario
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - S L Villa
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - P Mangili
- Medical Physics, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - P M V Rancoita
- University Center for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - C Cozzarini
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - M Picchio
- Vita-Salute San Raffaele University, Milan, Italy
- Department of Nuclear Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - A Del Vecchio
- Medical Physics, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - C Fiorino
- Medical Physics, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - M C S Di Serio
- University Center for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - A Chiti
- Vita-Salute San Raffaele University, Milan, Italy
- Department of Nuclear Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - N G Di Muzio
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Volpe F, Nappi C, Piscopo L, Zampella E, Mainolfi CG, Ponsiglione A, Imbriaco M, Cuocolo A, Klain M. Emerging Role of Nuclear Medicine in Prostate Cancer: Current State and Future Perspectives. Cancers (Basel) 2023; 15:4746. [PMID: 37835440 PMCID: PMC10571937 DOI: 10.3390/cancers15194746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
Prostate cancer is the most frequent epithelial neoplasia after skin cancer in men starting from 50 years and prostate-specific antigen (PSA) dosage can be used as an early screening tool. Prostate cancer imaging includes several radiological modalities, ranging from ultrasonography, computed tomography (CT), and magnetic resonance to nuclear medicine hybrid techniques such as single-photon emission computed tomography (SPECT)/CT and positron emission tomography (PET)/CT. Innovation in radiopharmaceutical compounds has introduced specific tracers with diagnostic and therapeutic indications, opening the horizons to targeted and very effective clinical care for patients with prostate cancer. The aim of the present review is to illustrate the current knowledge and future perspectives of nuclear medicine, including stand-alone diagnostic techniques and theragnostic approaches, in the clinical management of patients with prostate cancer from initial staging to advanced disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Michele Klain
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (F.V.); (C.N.); (L.P.); (E.Z.); (C.G.M.); (A.P.); (M.I.); (A.C.)
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Negative 11C-choline PET/computed tomography imaging in restaging of patients with prostate cancer with serum prostate-specific antigen values >20 ng/mL. Nucl Med Commun 2021; 41:1178-1182. [PMID: 32804916 DOI: 10.1097/mnm.0000000000001266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Several studies have reported about the performance of C-choline-PET/computed tomography (CT) (choline) in patients with biochemical recurrent (BCR) prostate cancer, but there is a lack of information regarding negative choline in the same clinical setting. Our aim was to retrospectively analyse negative choline in a cohort of BCR-patients with high prostate-specific antigen (PSA). METHODS AND RESULTS We retrospectively analysed all choline-scans performed at two high-volume imaging centres between 2005 and 2018, selecting those of interest according to the following inclusion criteria: (1) proven prostate cancer treated either with radical prostatectomy or primary external beam radiation therapy (EBRT), (2) BCR after radical prostatectomy or EBRT, (3) PSA serum values >20 ng/mL at the time of scan and (4) scan reported as negative for active disease. Overall, among 5792 scans performed for BCR-prostate cancer, 14 matched the inclusion criteria and were classified as follows: 5/14(36%) inaccurate reports, 3/14(21%) questionable underestimation of positive findings, originally described as unclear, 6/14(43%) negatives. Choline showed a high detection rate in BCR-prostate cancer patients with PSA >20 ng/mL. CONCLUSIONS Although negative reports can be found in this clinical setting, in our review various disease-relevant findings were identified in more than half of the cases originally reported as negative warranting a double reading in such cases to avoid false-negative reports.
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Deconinck S, Tosco L, Merckx L, Gheysens O, Deroose CM, Baldewijns M, Weynand B, Laere KV, Oyen R, Poppel HV, Joniau S, Goffin KE. Anatomical mapping of lymph nodes in patients receiving salvage lymphadenectomy based on a positive 11C-choline positron emission tomography/computed tomography scan. Cent European J Urol 2019; 72:232-239. [PMID: 31720023 PMCID: PMC6830482 DOI: 10.5173/ceju.2019.1910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/26/2019] [Accepted: 08/09/2019] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION This paper aims to assess the diagnostic accuracy of an 11C-choline positron emission tomography/computed tomography (PET/CT) scan in the detection of lymph node (LN) metastases in patients with biochemical recurrence after radically treated prostate cancer (PCa), as compared to histology. The secondary goal is to depict spreading patterns of metastatic LNs in recurrent PCa. MATERIAL AND METHODS A single center retrospective study comprising of 30 patients who underwent retroperitoneal and/or pelvic salvage lymph node dissection (LND) due to 11C-choline PET/CT-positive nodal recurrences after radical treatment (median Prostate Specific Antigen (PSA) 1.5 ng/ml, range 0.2-11.4). Positive nodes on the preoperative PET/CT scans were mapped and compared to post-operative pathology results.LNs were marked as true positive, false positive, true negative and false negative and a patient- and a region-based analysis was performed. Sensitivity, specificity and positive/negative predictive value (PPV/NPV) were calculated. RESULTS Sixty positive LNs were detected on PET/CT with a median number of two positive nodes per patient (range 1-6). In 29 patients, a super-extended pelvic LND (PLND) was performed combined with a retroperitoneal LND (RPLND) in 13 of those cases. One patient underwent an inguinal LND. One hundred thirty-seven of 644 resected LNs contained metastases. The 11C-choline PET/CT scan correctly predicted 31 positive nodes (55%) while 25 nodes were falsely positive (45%). One hundred and six histologically proven metastatic nodes were not detected on the 11C-choline PET/CT scan (77%). Sensitivity, specificity, PPV and NPV of the 11C-choline PET/CT were 23%, 95%, 55% and 82%, respectively. CONCLUSIONS 11C-choline PET/CT has a relatively low detection rate and a moderate PPV for metastatic LNs in patients with biochemical recurrence after radically treated PCa.
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Affiliation(s)
- Steven Deconinck
- Department of Urology, AZ Sint-Blasius, Dendermonde, Belgium
- Department of Urology, Humanitas Gradenigo Hospital, Turin, Italy
| | - Lorenzo Tosco
- Urology, Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
- Department of Urology, Humanitas Gradenigo Hospital, Turin, Italy
| | - Luc Merckx
- Department of Urology, AZ Sint-Lucas, Ghent, Belgium
| | - Olivier Gheysens
- Nuclear Medicine, UZ Leuven, Leuven, Belgium
- Nuclear Medicine & Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Christophe M. Deroose
- Nuclear Medicine, UZ Leuven, Leuven, Belgium
- Nuclear Medicine & Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | | | | | | | | | - Hein Van Poppel
- Urology, Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
| | - Steven Joniau
- Urology, Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
| | - Karolien E. Goffin
- Nuclear Medicine, UZ Leuven, Leuven, Belgium
- Nuclear Medicine & Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
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De Visschere PJ, Standaert C, Fütterer JJ, Villeirs GM, Panebianco V, Walz J, Maurer T, Hadaschik BA, Lecouvet FE, Giannarini G, Fanti S. A Systematic Review on the Role of Imaging in Early Recurrent Prostate Cancer. Eur Urol Oncol 2019; 2:47-76. [DOI: 10.1016/j.euo.2018.09.010] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 09/17/2018] [Accepted: 09/24/2018] [Indexed: 12/20/2022]
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Liao XL, Wei JB, Li YQ, Zhong JH, Liao CC, Wei CY. Functional Magnetic Resonance Imaging in the Diagnosis of Locally Recurrent Prostate Cancer: Are All Pulse Sequences Helpful? Korean J Radiol 2018; 19:1110-1118. [PMID: 30386142 PMCID: PMC6201967 DOI: 10.3348/kjr.2018.19.6.1110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 04/24/2018] [Indexed: 11/16/2022] Open
Abstract
Objective To perform a meta-analysis to quantitatively assess functional magnetic resonance imaging (MRI) in the diagnosis of locally recurrent prostate cancer. Materials and Methods A comprehensive search of the PubMed, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews was conducted from January 1, 1995 to December 31, 2016. Diagnostic accuracy was quantitatively pooled for all studies by using hierarchical logistic regression modeling, including bivariate modeling and hierarchical summary receiver operating characteristic (HSROC) curves (AUCs). The Z test was used to determine whether adding functional MRI to T2-weighted imaging (T2WI) results in significantly increased diagnostic sensitivity and specificity. Results Meta-analysis of 13 studies involving 826 patients who underwent radical prostatectomy showed a pooled sensitivity and specificity of 91%, and the AUC was 0.96. Meta-analysis of 7 studies involving 329 patients who underwent radiotherapy showed a pooled sensitivity of 80% and specificity of 81%, and the AUC was 0.88. Meta-analysis of 11 studies reporting 1669 sextant biopsies from patients who underwent radiotherapy showed a pooled sensitivity of 54% and specificity of 91%, and the AUC was 0.85. Sensitivity after radiotherapy was significantly higher when diffusion-weighted MRI data were combined with T2WI than when only T2WI results were used. This was true when meta-analysis was performed on a per-patient basis (p = 0.027) or per sextant biopsy (p = 0.046). A similar result was found when 1H-magnetic resonance spectroscopy (1H-MRS) data were combined with T2WI and sextant biopsy was the unit of analysis (p = 0.036). Conclusion Functional MRI data may not strengthen the ability of T2WI to detect locally recurrent prostate cancer in patients who have undergone radical prostatectomy. By contrast, diffusion-weight MRI and 1H-MRS data may improve the sensitivity of T2WI for patients who have undergone radiotherapy.
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Affiliation(s)
- Xiao-Li Liao
- Department of First Chemotherapy, Affiliated Tumor Hospital of Guangxi Medical University, Nanning 530021, China
| | - Jun-Bao Wei
- Department of Therapeutic Radiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning 530021, China
| | - Yong-Qiang Li
- Department of First Chemotherapy, Affiliated Tumor Hospital of Guangxi Medical University, Nanning 530021, China
| | - Jian-Hong Zhong
- Department of Hepatobiliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning 530021, China
| | - Cheng-Cheng Liao
- Department of Third Chemotherapy, Affiliated Tumor Hospital of Guangxi Medical University, Nanning 530021, China
| | - Chang-Yuan Wei
- Department of Breast Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning 530021, China
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The utility of PET-based imaging for prostate cancer biochemical recurrence: a systematic review and meta-analysis. World J Urol 2018; 37:1239-1249. [PMID: 30003375 DOI: 10.1007/s00345-018-2403-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/07/2018] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Conventional imaging modalities have been poor in characterizing the true extent of disease in men with biochemical recurrence following primary treatment for prostate cancer. Functional imaging with positron emission tomography (PET) has shown promise of being a superior imaging modality. We conducted a systematic review and meta-analysis to define the diagnostic accuracy of PET/CT using 11C-choline, 18F-FACBC, or 68Ga-PSMA in detecting recurrent prostate cancer. METHODS We searched multiple databases in line with the preferred reporting items for systematic review and meta-analysis (PRISMA) statement to define the diagnostic accuracy of 11C-choline, 18F-FACBC, or 68Ga-PSMA PET/CT. Only studies secondarily staging participants with biochemical recurrence and those with an appropriate reference standard (pathology, further imaging, and/or clinical response) were eligible for analysis. RESULTS Twenty-one studies with 3202 participants met the inclusion criteria. Of these, 11C-choline, 18F-FACBC, and 68Ga-PSMA were the tracer investigated in 16, 5, and 1 studies, respectively. The summary sensitivity for each tracer was 80.9% (95% CI 70.4-88.3%), 79.7% (95% CI 51.9-93.4%), and 76.4% (95% CI 68.3-82.9%), respectively. The corresponding summary specificity was 84.1% (95% CI 70.2-92.2%), 61.9% (95% CI 41.1-79.0%), and 99.8% (95% CI 97.5-100%), respectively. Detection rates ranged between 58.6 and 82.8%. All included studies were judged to be at high risk of bias primarily due to study limitations pertaining to the reference standard. CONCLUSION There is a lack of high-quality data to verify the accuracy of PET-based imaging using 11C-choline, 18F-FACBC, or 68Ga-PSMA. The early results are encouraging that these techniques are superior to conventional imaging modalities, which would allow salvage therapies to be optimized.
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68Ga-PSMA and 11C-Choline comparison using a tri-modality PET/CT-MRI (3.0 T) system with a dedicated shuttle. Eur J Hybrid Imaging 2018; 2:9. [PMID: 29782606 PMCID: PMC5954786 DOI: 10.1186/s41824-018-0027-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/17/2018] [Indexed: 12/05/2022] Open
Abstract
Background The aim of this study was to prospectively compare the detection rate of 68Ga-PSMA versus 11C-Choline in men with prostate cancer with biochemical recurrence and to demonstrate the added value of a tri-modality PET/CT-MRI system. Methods We analysed 36 patients who underwent both 11C-Choline PET/CT and 68Ga-PSMA PET/CT scanning within a time window of 1-2 weeks. Additionally, for the 68Ga-PSMA scan, we used a PET/CT-MRI (3.0 T) system with a dedicated shuttle, acquiring MRI images of the pelvis. Results Both scans were positive in 18 patients (50%) and negative in 8 patients (22%). Nine patients were positive with 68Ga-PSMA alone (25%) and one with 11C-Choline only (3%). The median detected lesion per patient was 2 for 68Ga-PSMA (range 0-93) and 1 for 11C-Choline (range 0-57). Tumour to background ratios in all concordant lesions (n = 96) were higher for 68Ga-PSMA than for 11C-Choline (110.3 ± 107.8 and 27.5 ± 17.1, mean ± S.D., for each tracer, respectively P = 0.0001). The number of detected lesions per patient was higher for 11C-Choline in those with PSA ≥ 3.3 ng/mL, while the number of detected lesions was independent of PSA levels for 68Ga-PSMA using the same PSA cut-off value. Metastatic pelvic lesions were found in 25 patients (69%) with 68Ga-PSMA PET/CT, in 18 (50%) with 11C-Choline PET/CT and in 21 (58%) with MRI (3.0 T). MRI was very useful in detecting recurrence in cases classified as indeterminate by means of PET/CT alone at prostate bed. Conclusions In patients with prostate cancer with biochemical recurrence 68Ga-PSMA detected more lesions per patient than 11C-Choline, regardless of PSA levels. PET/CT-MRI (3.0 T) system is a feasible imaging modality that potentially adds useful relevant information with increased accuracy of diagnosis.
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Wei J, Zhu H, Liao X. Trigger pSA predicting recurrence from positive choline PET/CT with prostate cancer after initial treatment. Oncotarget 2018; 9:14630-14641. [PMID: 29581869 PMCID: PMC5865695 DOI: 10.18632/oncotarget.24318] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 12/13/2017] [Indexed: 12/16/2022] Open
Abstract
Purpose To assess the relationship between the diagnostic accuracy of Choline positron emission tomography/computed tomography (PET/CT) and the trigger prostate-specific antigen (PSA) level in patients with a biochemical recurrence of prostate cancer. Materials and Methods A meta-analysis was conducted to synthesize data across multiple studies. Results The pooled sensitivity and specificity of choline PET/CT were 82% (95% Confidence Interval (CI):80-84%) and 92% (95%CI: 90-93%), respectively. The pooled sensitivity and specificity of 18F-choline PET/CT were 81% (95%CI: 78-84%) and 90% (95%CI: 85-93%), respectively. The pooled sensitivity and specificity of 11C-choline PET/CT were 83% (95% CI: 80-86%) and 92% (95% CI: 90-94%), respectively. The pooled detection rate of 18F-choline PET/CT and 11C-choline PET/CT were 58% (95% CI: 48-68%) and 58% (95%CI: 49-68%), respectively. Conclusions Trigger PSA is an important risk factor for positive findings of Choline PET/CT and the detection rate of Choline PET/CT for recurrent prostate cancer increased in parallel with raises in PSA-values. Choline PET/CT got higher detection rate while the trigger PSA > 2ng/ml.
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Affiliation(s)
- Junbao Wei
- Department of Therapeutic Radiology, Guangxi Autonomous Regional Cancer Hospital & Cancer Hospital of Guangxi Medical University, Nanning, 530021, China
| | - Hengzong Zhu
- Department of General Medicine, Longan Hospital of Traditional Chinese Medicine, Nanning, 532700, China
| | - Xiaoli Liao
- The Oncology Department, Guangxi Autonomous Regional Cancer Hospital & Cancer Hospital of Guangxi Medical University, Nanning, 530021, China
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Mapelli P, Incerti E, Ceci F, Castellucci P, Fanti S, Picchio M. 11C- or 18F-Choline PET/CT for Imaging Evaluation of Biochemical Recurrence of Prostate Cancer. J Nucl Med 2017; 57:43S-48S. [PMID: 27694171 DOI: 10.2967/jnumed.115.169755] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 04/27/2016] [Indexed: 01/02/2023] Open
Abstract
Recurrence of prostate cancer is suspected when an increase in the prostate-specific antigen level is detected after radical treatment; the recurrence could be local relapse, distant relapse, or both. Differentiation between the two patterns of relapse is critical for choosing the proper treatment strategy. Choline PET/CT could be of help in discriminating patients with local, lymph node, and bone recurrences, thus having an impact on patient management.
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Affiliation(s)
- Paola Mapelli
- Unit of Nuclear Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy; and
| | - Elena Incerti
- Unit of Nuclear Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy; and
| | - Francesco Ceci
- Unit of Nuclear Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Paolo Castellucci
- Unit of Nuclear Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Stefano Fanti
- Unit of Nuclear Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Maria Picchio
- Unit of Nuclear Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy; and
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68Ga-PSMA-PET/CT in Patients With Biochemical Prostate Cancer Recurrence and Negative 18F-Choline-PET/CT. Clin Nucl Med 2017; 41:515-21. [PMID: 26975008 DOI: 10.1097/rlu.0000000000001197] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Investigating the value of Ga-PSMA-PET/CT in biochemically recurring prostate cancer patients with negative F-choline-PET/CT. PATIENTS AND METHODS One hundred thirty-nine consecutive patients with biochemical recurrence after curative (surgery and/or radiotherapy) therapy were offered participation in this sequential clinical imaging approach. Patients first underwent an F-choline-PET/CT. If negative, an additional Ga-PSMA-PET/CT was offered. One hundred twenty-five of 139 eligible patients were included in the study; 32 patients underwent additional Ga-PSMA-PET/CT. Patients with equivocal findings (n = 5) on F-choline-PET/CT and those who declined the additional Ga-PSMA-PET/CT (n = 9) were excluded. Images were analyzed visually for the presence of suspicious lesions. Findings on PET/CT were correlated with PSA level, PSA doubling time (dt), and PSA velocity (vel). RESULTS The overall detection rates were 85.6% (107/125) for the sequential imaging approach and 74.4% (93/125) for F-choline-PET/CT alone. Ga-PSMA-PET/CT detected sites of recurrence in 43.8% (14/32) of the choline-negative patients. Detection rates of the sequential imaging approach and F-choline-PET/CT alone increased with higher serum PSA levels and PSA vel. Subgroup analysis of Ga-PSMA-PET/CT in F-choline negative patients revealed detection rates of 28.6%, 45.5%, and 71.4% for PSA levels of 0.2 or greater to less than 1 ng/mL, 1 to 2 ng/mL, and greater than 2 ng/mL, respectively. CONCLUSIONS The sequential imaging approach designed to limit Ga-PSMA imaging to patients with negative choline scans resulted in high detection rates. Ga-PSMA-PET/CT identified sites of recurrent disease in 43.8% of the patients with negative F-choline PET/CT scans.
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Kilcoyne A, Price MC, McDermott S, Harisinghani MG. Imaging on nodal staging of prostate cancer. Future Oncol 2016; 13:551-565. [PMID: 27785926 DOI: 10.2217/fon-2016-0216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Prostate cancer is the second most common cancer in men and is the second highest cause of cancer death in men of all races. Accurate lymph node staging is essential to ensure adequate treatment of prostate cancer. Historically, conventional imaging methods have demonstrated limited sensitivity and specificity in the detection of lymph node metastases. There are many emerging PET tracers that have recently proven to be effective. In addition, the use of ultrasmall iron oxide nanoparticle-enhanced MRI has demonstrated promising results. This review outlines the strengths and limitations of each of the different imaging modalities as well as individual tracers used, including preclinical and clinical agents.
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Affiliation(s)
- Aoife Kilcoyne
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, MA, USA
| | - Melissa C Price
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, MA, USA
| | - Shaunagh McDermott
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, MA, USA
| | - Mukesh G Harisinghani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, MA, USA
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Walz J, Pignot G, Salem N, Brunelle S, Gravis G, Brenot-Rossi I. The urologist’s unmet clinical needs in prostate cancer. Clin Transl Imaging 2016. [DOI: 10.1007/s40336-016-0199-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Rauscher I, Maurer T, Beer AJ, Graner FP, Haller B, Weirich G, Doherty A, Gschwend JE, Schwaiger M, Eiber M. Value of 68Ga-PSMA HBED-CC PET for the Assessment of Lymph Node Metastases in Prostate Cancer Patients with Biochemical Recurrence: Comparison with Histopathology After Salvage Lymphadenectomy. J Nucl Med 2016; 57:1713-1719. [PMID: 27261524 DOI: 10.2967/jnumed.116.173492] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 04/27/2016] [Indexed: 01/05/2023] Open
Abstract
The purpose of this study was to evaluate the accuracy of Glu-NH-CO-NH-Lys-(Ahx)-[68Ga(HBED-CC)] PET compared with morphologic imaging for the assessment of lymph node metastases (LNM) in patients with recurrent prostate cancer. METHODS Forty-eight patients (median age, 71 y; interquartile range, 66-74 y) with biochemical recurrence (median prostate-specific antigen level, 1.31 ng/mL; interquartile range, 0.75-2.55 ng/mL) who underwent 68Ga-prostate-specific membrane antigen (PSMA) HBED-CC PET/CT or PET/MR and salvage lymphadenectomy were retrospectively included. Institutional review board approval and written informed consent were obtained from all patients for the purpose of anonymized evaluation and publication of their data. Standardized predefined lymph node (LN) template fields (n = 10) were evaluated in 68Ga-PSMA HBED-CC PET and morphologic imaging for the presence of LNM using a 5-point-scale. Additionally, SUVmean/max and size of suspicious lesions were determined. Specificity of 68Ga-PSMA HBED-CC PET imaging for PET-positive LNs was defined by comparison to histopathology. The diagnostic accuracy of 68Ga-PSMA HBED-CC PET compared with morphologic imaging alone was assessed, and areas under the receiver-operating-characteristic curves are presented. RESULTS LNM were found histologically in 68 of 179 resected anatomic LN fields (38.0%). The specificity of 68Ga-PSMA HBED-CC PET and morphologic imaging was 97.3% and 99.1%, respectively. However, 68Ga-PSMA HBED-CC PET detected LNM in 53 of 68 histopathologically proven metastatic LN fields (77.9%) whereas morphologic imaging was positive in only 18 of 67 (26.9%). 68Ga-PSMA HBED-CC PET imaging performed significantly superior to morphologic imaging for detection of LNM (difference in the areas under the receiver-operating-characteristic curves, 0.139; 95% confidence interval, 0.063-0.214; P < 0.001). In 68Ga-PSMA HBED-CC PET, the mean size of PET-positive LN measured by CT or MRI was 8.3 ± 4.3 mm (range, 4-25 mm), and LNs, which were suspicious only in CT or MRI, presented with a mean size of 13.0 ± 4.9 mm (range, 8-25 mm). CONCLUSION 68Ga-PSMA HBED-CC PET imaging is a promising method for early detection of LNM in patients with biochemical recurrent prostate cancer. It is more accurate than morphologic imaging and thus might represent a valuable tool for guiding salvage lymphadenectomy.
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Affiliation(s)
- Isabel Rauscher
- Department of Nuclear Medicine, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Tobias Maurer
- Department of Urology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Ambros J Beer
- Department of Nuclear Medicine, University Hospital Ulm, Ulm, Germany
| | - Frank-Philipp Graner
- Department of Nuclear Medicine, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Bernhard Haller
- Institute of Medical Statistics and Epidemiology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Gregor Weirich
- Department of Pathology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany; and
| | - Alan Doherty
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - Jürgen E Gschwend
- Department of Urology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Markus Schwaiger
- Department of Nuclear Medicine, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Matthias Eiber
- Department of Nuclear Medicine, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
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Fodor A, Berardi G, Fiorino C, Picchio M, Busnardo E, Kirienko M, Incerti E, Dell'Oca I, Cozzarini C, Mangili P, Pasetti M, Calandrino R, Gianolli L, Di Muzio NG. Toxicity and efficacy of salvage carbon 11-choline positron emission tomography/computed tomography-guided radiation therapy in patients with lymph node recurrence of prostate cancer. BJU Int 2016; 119:406-413. [DOI: 10.1111/bju.13510] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Andrei Fodor
- Department of Radiation Oncology; San Raffaele Scientific Institute; Milan Italy
| | - Genoveffa Berardi
- Department of Radiation Oncology; San Raffaele Scientific Institute; Milan Italy
| | - Claudio Fiorino
- Department of Medical Physics; San Raffaele Scientific Institute; Milan Italy
| | - Maria Picchio
- Department of Nuclear Medicine; San Raffaele Scientific Institute; Milan Italy
| | - Elena Busnardo
- Department of Nuclear Medicine; San Raffaele Scientific Institute; Milan Italy
| | | | - Elena Incerti
- Department of Nuclear Medicine; San Raffaele Scientific Institute; Milan Italy
| | - Italo Dell'Oca
- Department of Radiation Oncology; San Raffaele Scientific Institute; Milan Italy
| | - Cesare Cozzarini
- Department of Radiation Oncology; San Raffaele Scientific Institute; Milan Italy
| | - Paola Mangili
- Department of Medical Physics; San Raffaele Scientific Institute; Milan Italy
| | - Marcella Pasetti
- Department of Radiation Oncology; San Raffaele Scientific Institute; Milan Italy
| | - Riccardo Calandrino
- Department of Medical Physics; San Raffaele Scientific Institute; Milan Italy
| | - Luigi Gianolli
- Department of Nuclear Medicine; San Raffaele Scientific Institute; Milan Italy
| | - Nadia G Di Muzio
- Department of Radiation Oncology; San Raffaele Scientific Institute; Milan Italy
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16
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PET/CT with (11)C-choline for evaluation of prostate cancer patients with biochemical recurrence: meta-analysis and critical review of available data. Eur J Nucl Med Mol Imaging 2015; 43:55-69. [PMID: 26450693 DOI: 10.1007/s00259-015-3202-7] [Citation(s) in RCA: 156] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/17/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE For the last decade PET and PET/CT with (11)C-choline have been proposed for the evaluation of prostate cancer (PC), but the diagnostic performance of (11)C-choline PET/CT is still a matter of debate. We performed a comprehensive review of the most important clinical application of (11)C-choline PET, restaging of patients with biochemical relapse, following a rigorous methodological approach and including assessment of the risk of bias. We conducted a systematic review and meta-analysis of the literature assessing (11)C-choline PET/CT for its accuracy in the diagnosis and ability to detect the site of recurrence of PC in the restaging of patients with biochemical recurrence after initial treatment with curative intent. METHODS We performed a comprehensive literature search of PubMed and the Cochrane Library to determine the accuracy for the detection of the site of recurrence (prostate bed recurrences, metastatic spread to locoregional pelvic lymph nodes or distant metastases). Only studies with a reference standard (for prostatic bed histopathology, for histopathology or biopsy of distant metastases or a composite reference standard with clinical follow-up of at least 12 months, correlative imaging and clinical data) were included. RESULTS Overall 425 studies were retrieved, of which 43 were judged as potentially relevant and 29 with 2,686 participants were finally included. Of these 29 studies, 18 reported results for any relapse, All 18 studies, with a total of 2,126 participants, reported detection rates. The pooled rate was 62 % (95 % CI 53 - 71 %). Of the 18 studies, 12 with 1,270 participants reported useful data to derive sensitivity and specificity. The pooled sensitivity was 89 % (95 % CI 83 - 93 %) and the pooled specificity was 89 % (95 % CI 73 - 96 %). Of 11 studies reporting results for local relapse, 9 with 993 participants reported detection rates. The pooled rate was 27 % (95 % CI 16 - 38 %). Six studies with 491 participants reported sensitivity and specificity. The pooled sensitivity was 61 % (95 % CI 40 - 80 %) and the pooled specificity was 97 % (95 % CI 87 - 99 %). Ten studies reported results for lymph nodes and distant metastases. For nodal disease, 7 studies with 752 participants reported detection rates. The pooled rate was 36 % (95 % CI 22 - 50 %). For bone metastases, 8 studies with 775 participants reported detection rates. The pooled rate was 25 % (95 % CI 16 - 34 %). CONCLUSION There is a significant amount of (11)C-choline PET data published showing a high degree of consistency in inclusion criteria, acquisition protocols and scan interpretation criteria. Furthermore, the quality of the data derived limited to the same standard of reference was acceptable. Despite a high variability in the observed prevalence of any relapse, the diagnostic performance of (11)C-choline PET was in line with previous meta-analyses. Our data confirm the very good accuracy of (11)C-choline PET for detection of lymph node metastases and/or distant lesions in a single examination in patients with biochemical relapse.
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Ouyang Q, Duan Z, Lei J, Jiao G. Comparison of meta-analyses among elastosonography (ES) and positron emission tomography/computed tomography (PET/CT) imaging techniques in the application of prostate cancer diagnosis. Tumour Biol 2015; 37:2999-3007. [PMID: 26415734 DOI: 10.1007/s13277-015-4113-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/20/2015] [Indexed: 10/23/2022] Open
Abstract
The early diagnosis of prostate cancer (PCa) appears to be of vital significance for the provision of appropriate treatment programs. Even though several sophisticated imaging techniques such as positron emission tomography/computed tomography (PET/CT) and elastosonography (ES) have already been developed for PCa diagnosis, the diagnostic accuracy of these imaging techniques is still controversial to some extent. Therefore, a comprehensive meta-analysis in this study was performed to compare the accuracy of various diagnostic imaging methods for PCa, including 11C-choline PET/CT, 11C-acetate PET/CT, 18F-fluorocholine PET/CT, 18F-fluoroglucose PET/CT, transrectal real-time elastosonography (TRTE), and shear-wave elastosonography (SWE). The eligible studies were identified through systematical searching for the literature in electronic databases including PubMed, Cochrane, and Web of Science. On the basis of the fixed-effects model, the pooled sensitivity (SEN), specificity (SPE), and area under the receiver operating characteristics curve (AUC) were calculated to estimate the diagnostic accuracy of 11C-choline PET/CT, 11C-acetate PET/CT, 18F-fluorocholine (FCH) PET/CT, 18F-fluoroglucose (FDG) PET/CT, TRTE, and SWE. All the statistical analyses were conducted with R language Software. The present meta-analysis incorporating a total of 82 studies demonstrated that the pooled sensitivity of the six imaging techniques were sorted as follows: SWE > 18F-FCH PET/CT > 11C-choline PET/CT > TRTE > 11C-acetate PET/CT > 18F-FDG PET/CT; the pooled specificity were also compared: SWE > 18F-FCH PET/CT > 11C-choline PET/CT > TRTE > 18F-FDG PET/CT > 11C-acetate PET/CT; finally, the pooled diagnostic accuracy of the six imaging techniques based on AUC were ranked as below: SWE > 18F-FCH PET/CT > 11C-choline PET/CT > TRTE > 11C-acetate PET/CT > 18F-FDG PET/CT. SWE and 18F-FCH PET/CT imaging could offer more assistance in the early diagnosis of PCa than any other studied imaging techniques. However, the diagnostic ranking of the six imaging techniques might not be applicable to the clinical phase due to the shortage of stratified analysis.
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Affiliation(s)
- Qiaohong Ouyang
- Department of Nuclear Medicine, The First Affiliated Hospital of Chinese PLA General Hospital, No. 51 Fucheng Road, Beijing, 100048, China.
| | - Zhongxiang Duan
- Department of Nuclear Medicine, The First Affiliated Hospital of Chinese PLA General Hospital, No. 51 Fucheng Road, Beijing, 100048, China
| | - Jixiao Lei
- Department of Nuclear Medicine, The First Affiliated Hospital of Chinese PLA General Hospital, No. 51 Fucheng Road, Beijing, 100048, China
| | - Guangli Jiao
- Department of Nuclear Medicine, The First Affiliated Hospital of Chinese PLA General Hospital, No. 51 Fucheng Road, Beijing, 100048, China
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Fan W, Zhang Z, Zhu Z, Yang D, Chen X, Wang J, Chen F, Song X. Synthesis and positron emission tomography evaluation of 18F-Glu-Urea-Lys, a prostate-specific membrane antigen-based imaging agent for prostate cancer. Oncol Lett 2015; 10:2299-2302. [PMID: 26622838 DOI: 10.3892/ol.2015.3625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 06/11/2015] [Indexed: 11/06/2022] Open
Abstract
In recent years, single-photon emission computed tomography and positron emission tomography (PET) have also been used, in addition to computed tomography and magnetic resonance imaging, in targeting the diagnosis of prostate cancer. The aim of this study was to synthesize the prostate-specific membrane antigen (PSMA)-based imaging agent 2-{3-[1-Carboxy-5-(4-[18F] fluoro-benzoylamino)-pentyl]-ureido}-pentanedioic acid (18F-Glu-Urea-Lys, [18F]3) and to detect its PET imaging efficiency for high PSMA expression in prostate cancer. In this study, 18F-Glu-Urea-Lys was synthesized in two steps from the p-methoxybenzyl-protected Glu-Urea-Lys precursor using N-Hydroxysuccinimidyl-4-[18F] fluorobenzoate ([18F]SFB). PET imaging evaluation was conducted in nude mice using LNCaP (PSMA+), and PC-3, 231 and A549 (all PSMA-) xenograft models. The results indicated that 18F-Glu-Urea-Lys was produced in radiochemical yields of 28.7%. The radiochemical purity was 99.1% and the mean total synthesis time was 168 min. In nude mice models 18F-Glu-Urea-Lys clearly delineated PSMA+ LNCaP prostate tumor xenografts on PET imaging. At 4 h post-injection, the contrast agents were only observed in renal, liver, bladder and PSMA+ LNCaP tumors. The PSMA- tumor (PC-3, 231 and A549) was clear. In conclusion, 18F-Glu-Urea-Lys was found to be easily synthesized. This radiotracer demonstrated high tumor and low-to-normal tissue uptake, fast clearance from non-target tissues and retention in PSMA+ prostate tumor xenografts.
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Affiliation(s)
- Weiwei Fan
- Graduate School, Dalian Medical University, Dalian, Liaoning 116085, P.R. China
| | - Zhiwei Zhang
- Graduate School, Dalian Medical University, Dalian, Liaoning 116085, P.R. China
| | - Zheng Zhu
- Graduate School, Dalian Medical University, Dalian, Liaoning 116085, P.R. China
| | - Deyong Yang
- Department of Urology Surgery, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116023, P.R. China
| | - Xiaochi Chen
- Department of Urology Surgery, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116023, P.R. China
| | - Jianbo Wang
- Department of Urology Surgery, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116023, P.R. China
| | - Feng Chen
- Department of Urology Surgery, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116023, P.R. China
| | - Xishuang Song
- Department of Urology Surgery, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116023, P.R. China
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Rylander S, Polders D, Steggerda MJ, Moonen LM, Tanderup K, Van der Heide UA. Re-distribution of brachytherapy dose using a differential dose prescription adapted to risk of local failure in low-risk prostate cancer patients. Radiother Oncol 2015; 115:308-13. [DOI: 10.1016/j.radonc.2015.05.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 05/14/2015] [Accepted: 05/17/2015] [Indexed: 11/15/2022]
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Kjölhede H, Ahlgren G, Almquist H, Liedberg F, Lyttkens K, Ohlsson T, Bratt O. 18F-choline PET/CT for early detection of metastases in biochemical recurrence following radical prostatectomy. World J Urol 2015; 33:1749-52. [DOI: 10.1007/s00345-015-1547-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 03/23/2015] [Indexed: 10/23/2022] Open
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Imagerie post-thérapeutique du cancer de la prostate. Prog Urol 2015; 25:128-37. [DOI: 10.1016/j.purol.2014.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 10/19/2014] [Accepted: 12/06/2014] [Indexed: 12/20/2022]
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22
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Winter A, Henke RP, Wawroschek F. Targeted salvage lymphadenectomy in patients treated with radical prostatectomy with biochemical recurrence: complete biochemical response without adjuvant therapy in patients with low volume lymph node recurrence over a long-term follow-up. BMC Urol 2015; 15:10. [PMID: 25881245 PMCID: PMC4344760 DOI: 10.1186/s12894-015-0004-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 02/05/2015] [Indexed: 11/13/2022] Open
Abstract
Background Choline positron emission tomography/computed tomography (PET/CT) represents an option in restaging of prostate cancer patients with disease relapse after local treatment. The present study assess whether salvage resection of lymph node metastases detected on choline PET/CT imaging in prostate cancer patients with biochemical recurrence after radical prostatectomy can result in a long-term complete biochemical remission, without adjuvant therapy. Methods We analysed 13 patients with prostate specific antigen (PSA) recurrence (PSA median 1.64 ng/ml, range 0.5-9.55) after radical prostatectomy and suspicious lymph nodes (median 1; range 1–3) detected on [11C]choline and [18F]fluoroethylcholine PET/CT scans. An open salvage lymphadenectomy of positive lymph nodes in a PET/CT scan and nearby lymph nodes was carried out. We examined PSA outcome without adjuvant therapy; defined complete biochemical remission as PSA <0.01 ng/ml. Histological and PET/CT findings were compared. Results Ten of 11 patients with histologically confirmed lymph node metastases showed a PSA response. Three of ten patients with single lymph node metastases had a complete biochemical remission (median follow-up 72 months, range 31.0-83). In five cases with single lymph node metastasis PSA decreased <0.02 ng/ml. Histologically confirmed 13 of 16 metastasis suspicious lymph nodes. No lymph node metastases were detected in two patients. All of the additionally removed 30 lymph nodes were correctly negative. Conclusions This is the first confirmation of a complete biochemical remission after PET/CT guided secondary resection of a single lymph node metastasis in prostate cancer patients with biochemical recurrence after radical prostatectomy, over the long-term (>6.5 years), without adjuvant therapy. In order to improve these promising results, longer-term studies with more patients are required.
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Affiliation(s)
- Alexander Winter
- University Hospital for Urology, Klinikum Oldenburg, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Rahel-Straus-Straße 10, 26133, Oldenburg, Germany.
| | | | - Friedhelm Wawroschek
- University Hospital for Urology, Klinikum Oldenburg, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Rahel-Straus-Straße 10, 26133, Oldenburg, Germany.
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23
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Giovacchini G, Incerti E, Mapelli P, Kirienko M, Briganti A, Gandaglia G, Montorsi F, Gianolli L, Picchio M. [¹¹C]Choline PET/CT predicts survival in hormone-naive prostate cancer patients with biochemical failure after radical prostatectomy. Eur J Nucl Med Mol Imaging 2015; 42:877-84. [PMID: 25697127 DOI: 10.1007/s00259-015-3015-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/02/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Over the last decade, PET/CT with radiolabelled choline has been shown to be useful for restaging patients with prostate cancer (PCa) who develop biochemical failure. The limitations of most clinical studies have been poor validation of [(11)C]choline PET/CT-positive findings and lack of survival analysis. The aim of this study was to assess whether [(11)C]choline PET/CT can predict survival in hormone-naive PCa patients with biochemical failure. METHODS This retrospective study included 302 hormone-naive PCa patients treated with radical prostatectomy who underwent [(11)C]choline PET/CT from 1 December 2004 to 31 July 2007 because of biochemical failure (prostate-specific antigen, PSA, >0.2 ng/mL). Median PSA was 1.02 ng/mL. PCa-specific survival was estimated using Kaplan-Meier curves. Cox regression analysis was used to evaluate the association between clinicopathological variables and PCa-specific survival. The coefficients of the covariates included in the Cox regression analysis were used to develop a novel nomogram. RESULTS Median follow-up was 7.2 years (1.4 - 18.9 years). [(11)C]Choline PET/CT was positive in 101 of 302 patients (33%). Median PCa-specific survival after prostatectomy was 14.9 years (95% CI 9.7 - 20.1 years) in patients with positive [(11)C]choline PET/CT. Median survival was not achieved in patients with negative [(11)C]choline PET/CT. The 15-year PCa-specific survival probability was 42.4% (95% CI 31.7 - 53.1%) in patients with positive [(11)C]choline PET/CT and 95.5% (95% CI 93.5 - 97.5 %) in patients with negative [(11)C]choline PET/CT. In multivariate analysis, [(11)C]choline PET/CT (hazard ratio 6.36, 95% CI 2.14 - 18.94, P < 0.001) and Gleason score >7 (hazard ratio 3.11, 95% CI 1.11 - 8.66, P = 0.030) predicted PCa-specific survival. An internally validated nomogram predicted 15-year PCa-specific survival probability with an accuracy of 80%. CONCLUSION Positive [(11)C]choline PET/CT after biochemical failure predicts PCa-specific survival in hormone-naive PCa patients. Prospective studies are warranted to confirm our results before more extensive use of [(11)C]choline PET/CT for prognostic stratification of PCa patients.
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Affiliation(s)
- Giampiero Giovacchini
- Department of Radiology and Nuclear Medicine, Stadtspital Triemli, Zurich, Switzerland
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Treglia G, Vigneri C, Sadeghi R, Evangelista L, Ceriani L, Giovanella L. Discordance rate between radiolabelled choline PET/CT and bone scintigraphy in detecting bone metastases in patients with prostate cancer: a meta-analysis. Clin Transl Imaging 2015. [DOI: 10.1007/s40336-015-0107-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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López E, Lazo A, Gutiérrez A, Arregui G, Núñez I, Sacchetti A. Influence of (11)C-choline PET/CT on radiotherapy planning in prostate cancer. Rep Pract Oncol Radiother 2014; 20:104-12. [PMID: 25859399 DOI: 10.1016/j.rpor.2014.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 10/19/2014] [Accepted: 11/20/2014] [Indexed: 12/13/2022] Open
Abstract
AIM To evaluate the influence of (11)C-choline PET/CT on radiotherapy planning in prostate cancer patients. BACKGROUND Precise information on the extension of prostate cancer is crucial for the choice of an appropriate therapeutic strategy. (11)C-choline positron emission tomography ((11)C-choline PET/CT) has two roles in radiation oncology (RT): (1) patient selection for treatment and (2) target volume selection and delineation. In conjunction with high-accuracy techniques, it might offer an opportunity of dose escalation and better tumour control while sparing healthy tissues. MATERIALS AND METHODS We carried out a retrospective study in order to analyse RT planning modification based on (11)C-choline PET/CT in 16 prostate cancer patients. Patients were treated with hypofractionated step-and-shoot Intensity Modulated Radiotherapy (IMRT), or Volumetric Modulated Arc Therapy (VMAT), and a daily cone-beam CT for Image Guided Radiation Therapy (IGRT). All patients underwent a (11)C-choline-PET/CT scan prior to radiotherapy. RESULTS In 37.5% of cases, a re-delineation and new dose prescription occurred. Data show good preliminary clinical results in terms of biochemical control and toxicity. No gastrointestinal (GI)/genitourinary (GU) grade III toxicities were observed after a median follow-up of 9.5 months. CONCLUSIONS In our experience, concerning the treatment of prostate cancer (PCa), (11)C-choline PET/CT may be helpful in radiotherapy planning, either for dose escalation or exclusion of selected sites.
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Affiliation(s)
- Escarlata López
- Radiotherapy and Oncology Department, ONCOSUR, Granada, Spain
| | - Antonio Lazo
- Radiotherapy and Oncology Department, ONCOSUR, Granada, Spain
| | | | | | - Isabel Núñez
- Radiology and Physical Medicine Department, Granada University, Spain
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Rischke HC, Schultze-Seemann W, Wieser G, Krönig M, Drendel V, Stegmaier P, Krauss T, Henne K, Volegova-Neher N, Schlager D, Kirste S, Grosu AL, Jilg CA. Adjuvant radiotherapy after salvage lymph node dissection because of nodal relapse of prostate cancer versus salvage lymph node dissection only. Strahlenther Onkol 2014; 191:310-20. [DOI: 10.1007/s00066-014-0763-5] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 09/19/2014] [Indexed: 01/07/2023]
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Abdollah F, Briganti A, Montorsi F, Stenzl A, Stief C, Tombal B, Van Poppel H, Touijer K. Contemporary role of salvage lymphadenectomy in patients with recurrence following radical prostatectomy. Eur Urol 2014; 67:839-49. [PMID: 24698524 DOI: 10.1016/j.eururo.2014.03.019] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 03/17/2014] [Indexed: 11/17/2022]
Abstract
CONTEXT Prostate cancer (PCa) patients with isolated clinical lymph node (LN) relapse, limited to the regional and/or retroperitoneal LNs, may represent a distinct group of patients who have a more favorable outcome than men with progression to the bone or to other visceral organs. Some data indirectly denote a beneficial impact of pelvic LN dissection on survival in these patients. OBJECTIVE To provide an overview of the currently available literature regarding salvage LN dissection (SLND) in PCa patients with clinical relapse limited to LNs after radical prostatectomy (RP). EVIDENCE ACQUISITION A systematic literature search was conducted using the Medline, Embase, and Web of Science databases to identify original articles, review articles, and editorials regarding SLND. Articles published between 2000 and 2012 were reviewed and selected with the consensus of all the authors. EVIDENCE SYNTHESIS Contemporary imaging techniques, such as 11C-choline positron emission tomography and diffusion-weighted magnetic resonance imaging, appear to enhance the accuracy in identifying LN relapse in patients with biochemical recurrence (BCR) and after RP. In these individuals, SLND can be considered as a treatment option. The currently available data suggest that SLND can delay clinical progression and postpone hormonal therapy in almost one-third of the patients, although the majority will have BCR. An accurate and attentive preoperative patient selection may help improve these outcomes. The most frequent complication after SLND was lymphorrhea (15.3%), followed by fever (14.5%) and ileus (11.2%). It is noteworthy that all examined cohorts originated from retrospective single-institution series, with limited sample size and short follow-up. Consequently, the current findings cannot be generalized and warrant further investigation in future prospective trials. CONCLUSIONS The current data suggest that SLND represents an option in patients with disease relapse limited to the LNs after RP; however, more robust data derived from well-designed clinical trials are needed to validate the role of SLND in this selected patient population. PATIENT SUMMARY Salvage lymph node dissection (SLND) represents a treatment option in for patients with prostate cancer relapse limited to the lymph nodes; however, more robust data derived from well-designed clinical trials are needed to validate the role of SLND in this selected patient population.
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Affiliation(s)
- Firas Abdollah
- Vattikuti Urology Institute and VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA.
| | - Alberto Briganti
- Department of Urology, Vita-Salute University, San Raffaele, Milan, Italy
| | - Francesco Montorsi
- Department of Urology, Vita-Salute University, San Raffaele, Milan, Italy
| | - Arnulf Stenzl
- Department of Urology, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Christian Stief
- Department of Urology, Ludwig-Maximilians-University, Klinikum Grosshadern, Munich, Germany
| | - Bertrand Tombal
- Service d'Urologie, Cliniques universitaires Saint Luc, Université catholique de Louvain, Brussels, Belgium
| | - Hein Van Poppel
- Department of Urology, Leuven Cancer Institute, Universitair Ziekenhuis Gasthuisberg, Leuven, Belgium
| | - Karim Touijer
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Advanced imaging for the early diagnosis of local recurrence prostate cancer after radical prostatectomy. BIOMED RESEARCH INTERNATIONAL 2014; 2014:827265. [PMID: 24757679 PMCID: PMC3971570 DOI: 10.1155/2014/827265] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 02/06/2014] [Indexed: 12/30/2022]
Abstract
Currently the diagnosis of local recurrence of prostate cancer (PCa) after radical prostatectomy (RT) is based on the onset of biochemical failure which is defined by two consecutive values of prostate-specific antigen (PSA) higher than 0.2 ng/mL. The aim of this paper was to review the current roles of advanced imaging in the detection of locoregional recurrence. A nonsystematic literature search using the Medline and Cochrane Library databases was performed up to November 2013. Bibliographies of retrieved and review articles were also examined. Only those articles reporting complete data with clinical relevance for the present review were selected. This review article is divided into two major parts: the first one considers the role of PET/CT in the restaging of PCa after RP; the second part is intended to provide the impact of multiparametric-MRI (mp-MRI) in the depiction of locoregional recurrence. Published data indicate an emerging role for mp-MRI in the depiction of locoregional recurrence, while the performance of PET/CT still remains unclear. Moreover Mp-MRI, thanks to functional techniques, allows to distinguish between residual glandular healthy tissue, scar/fibrotic tissue, granulation tissue, and tumour recurrence and it may also be able to assess the aggressiveness of nodule recurrence.
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Detection of lymph node metastasis in patients with nodal prostate cancer relapse using (18)F/(11)C-choline positron emission tomography/computerized tomography. J Urol 2014; 192:103-10. [PMID: 24518792 DOI: 10.1016/j.juro.2013.12.054] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2013] [Indexed: 11/24/2022]
Abstract
PURPOSE We evaluated the diagnostic accuracy of choline positron emission tomography/computerized tomography for nodal relapse of prostate cancer according to topographical site and tumor infiltration size in lymph nodes. MATERIALS AND METHODS A total of 72 patients with nodal prostate cancer relapse after primary therapy underwent pelvic and/or retroperitoneal salvage lymph node dissection. Salvage was done after whole body positron emission tomography/computerized tomography with (11)C-choline or (18)F-fluoroethylcholine showed positron emission tomography positive lymph nodes but no other detectable metastasis. Diagnostic accuracy was evaluated in 160 dissected lymph node regions (pelvic left/right and retroperitoneal), 498 subregions (common, external and internal iliac, obturator, presacral, aortic bifurcation, aortal, vena caval and interaortocaval) and 2,122 lymph nodes. RESULTS Lymph node metastasis was present in 32% of resected lymph nodes (681 of 2,122), resulting in 238 positive subregions and 111 positive regions. Positron emission tomography/computerized tomography was positive for 110 regions and 209 subregions. Sensitivity, specificity, positive and negative predictive values, and accuracy were 91.9%, 83.7%, 92.7%, 82.0% and 89.4% (region based), 80.7%, 93.5%, 91.9%, 84.1% and 87.3% (subregion based), and 57.0%, 98.4%, 94.5%, 82.6% and 84.9% (lesion based), respectively. Of 393 positive lymph node metastases detected by this method 278 (70.7%) were in lymph nodes with a less than 10 mm short axis diameter. Imaging sensitivity was 13.3%, 57.4% and 82.8% for a tumor infiltration depth of 2 or greater to less than 3 mm, 5 or greater to less than 6 mm and 10 or greater to less than 11 mm, respectively. Lymph node metastasis site and the radiotracer ((11)C-choline/(18)F-fluoroethylcholine) had no substantial impact on diagnostic accuracy. CONCLUSIONS Choline positron emission tomography/computerized tomography detects affected lymph node regions (pelvic left/right and retroperitoneal) in patients with prostate cancer relapse with high accuracy and it seems helpful for guiding salvage lymph node dissection. Sensitivity decreases with the size of metastatic infiltration in lymph nodes. This technique detects metastasis in a significant fraction of lymph nodes that are not pathologically enlarged on computerized tomography.
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Mikropoulos C, Goh C, Leongamornlert D, Kote-Jarai Z, Eeles R. Translating genetic risk factors for prostate cancer to the clinic: 2013 and beyond. Future Oncol 2014; 10:1679-94. [PMID: 25145435 DOI: 10.2217/fon.14.72] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Prostate cancer (PrCa) is the most commonly diagnosed cancer in the male UK population, with over 40,000 new cases per year. PrCa has a complex, polygenic predisposition, due to rare variants such as BRCA and common variants such as single nucleotide polymorphisms (SNPs). With the introduction of genome-wide association studies, 78 susceptibility loci (SNPs) associated with PrCa risk have been identified. Genetic profiling could risk-stratify a population, leading to the discovery of a higher proportion of clinically significant disease and a reduction in the morbidity related to age-based prostate-specific antigen screening. Based on the combined risk of the 78 SNPs identified so far, the top 1% of the risk distribution has a 4.7-times higher risk of developing PrCa compared with the average of the general population.
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Alongi F, De Bari B, Campostrini F, Arcangeli S, Matei DV, Lopci E, Petralia G, Bellomi M, Chiti A, Magrini SM, Scorsetti M, Orecchia R, Jereczek-Fossa BA. Salvage therapy of intraprostatic failure after radical external-beam radiotherapy for prostate cancer: A review. Crit Rev Oncol Hematol 2013; 88:550-63. [DOI: 10.1016/j.critrevonc.2013.07.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 05/20/2013] [Accepted: 07/17/2013] [Indexed: 01/29/2023] Open
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Choline PET or PET/CT and biochemical relapse of prostate cancer: a systematic review and meta-analysis. Clin Nucl Med 2013; 38:305-14. [PMID: 23486334 DOI: 10.1097/rlu.0b013e3182867f3c] [Citation(s) in RCA: 215] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM The increase of prostate-specific antigen (PSA) after radical retropubic prostatectomy (RP) or external beam radiotherapy (EBRT) is the most sensitive tool for detecting prostate cancer (PCa) recurrence, although this measure cannot distinguish between local, regional, or distant recurrence. The aim of this meta-analysis was to evaluate the diagnostic performance of 18F-choline and 11C-choline PET or PET/CT in detection of locoregional or distant metastases in PCa. MATERIALS AND METHODS Medline, Web of Knowledge, and Google Scholar search was carried out in order to select English-language articles dealing with diagnostic performance of both 18F-choline and 11C-choline PET for the detection of PCa recurrence after RP or EBRT. Articles were included only if absolute numbers of true-positive, true-negative, false-positive, and false-negative test results were available or derivable from the text and regarded local, lymph node, and distant metastases. Reviews, clinical reports, and editorial articles were excluded. All complete studies were re-analyzed thus performing a quantitative analysis. RESULTS From the years 2000 to 2012, we found 53 complete articles that critically evaluated the role of choline PET in restaging patients with PCa recurrence. The meta-analysis was carried out and dealt with 19 selected studies (12 studies for all sites of disease, 3 for lymph node metastases, and 4 for local recurrence), with a total of 1555 patients. The meta-analysis provided a pooled sensitivity of 85.6% (95% CI: 82.9%-88.1%) and pooled specificity of 92.6% (95% CI: 90.1%-94.6%) for all sites of disease (prostatic fossa, lymph nodes, and bone), a pooled sensitivity of 75.4% (95% CI: 66.9%-82.6%) and pooled specificity of 82% (95% CI: 68.6%-91.4%) for prostatic fossa recurrence, and a pooled sensitivity of 100% (95% CI: 90.5%-100%) and pooled specificity of 81.8% (95% CI: 48.2%-97.7%) for lymph node metastases. The heterogeneity ranged between 0.00% and 88.6%. The diagnostic odds ratios were 62.123 (95% CI: 24.783-155.72), 5.869 (95% CI: 1.818-18.946), and 138.57 (95% CI: 11.27-1703.8), respectively, for all sites of disease, local recurrence, and lymph node disease. CONCLUSIONS Choline PET and PET/CT represent high sensitivity and specificity techniques for the detection of locoregional and distant metastases in PCa patients with recurrence of disease. Moreover, a high diagnostic odds ratio was found for the identification of lymph node disease in patients with biochemical recurrence of PCa.
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Kitajima K, Murphy RC, Nathan MA, Sugimura K. Update on positron emission tomography for imaging of prostate cancer. Int J Urol 2013; 21:12-23. [PMID: 23991644 DOI: 10.1111/iju.12250] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 07/10/2013] [Indexed: 12/11/2022]
Abstract
Prostate cancer is the most common non-cutaneous malignancy among men in the Western world, and continues to be a major health problem. Imaging has recently become more important in the clinical management of prostate cancer patients, including diagnosis, staging, choice of optimal treatment strategy, treatment follow up and restaging. Positron emission tomography, a functional and molecular imaging technique, has opened a new field in clinical oncological imaging. The most common positron emission tomography radiotracer, 18F-fluorodeoxyglucose, has been limited in imaging of prostate cancer. Recently, however, other positron emission tomography tracers, such as 11C-acetate and 11C- or (18) F-choline, have shown promising results. In the present review article, we overview the potential and current use of positron emission tomography or positron emission tomography/computed tomography imaging employing the four most commonly used positron emission tomography radiotracers, 18F-fluorodeoxyglucose, 11C-acetate and 11C- or 18F-choline, for imaging evaluation of prostate cancer.
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Affiliation(s)
- Kazuhiro Kitajima
- Department of Radiology, Kobe University School of Medicine, Kobe, Japan
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Alongi F, Liardo RLE, Iftode C, Lopci E, Villa E, Comito T, Tozzi A, Navarria P, Ascolese AM, Mancosu P, Tomatis S, Bellorofonte C, Arturo C, Scorsetti M. 11C choline PET guided salvage radiotherapy with volumetric modulation arc therapy and hypofractionation for recurrent prostate cancer after HIFU failure: preliminary results of tolerability and acute toxicity. Technol Cancer Res Treat 2013; 13:395-401. [PMID: 24000995 PMCID: PMC4527415 DOI: 10.7785/tcrtexpress.2013.600268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The purpose of this work was to evaluate tolerance, feasibility and acute toxicity in patients undergoing salvage radiotherapy after high-intensity focused ultrasound (HIFU) failure. From 2005 to 2011 a total of 15 patients were treated with HIFU as primary radical treatment. Between July 2011 and February 2013, all 15 patients presented biochemical relapse after HIFU and 11C choline PET documenting intrapostatic-only failure. Salvage EBRT was performed with moderate hypofractionation schedule in 28 fractions with volumetric modulation arc therapy (VMAT). Genito-urinary (GU) and rectal and bowel toxicity were scored by common terminology criteria for adverse events version 4 (CTCAE V.4) scale. Biochemical response was assessed by ASTRO Phoenix criteria. Median age of patients was 67 years (range: 53-85). The median Gleason score was 7 (range: 6-9). The median prostate specific antigen (PSA) at the time of biochemical relapse after HIFU was 5.2 ng/mL (range: 2-64.2). Seven of the 15 patients received androgen deprivation therapy (ADT) started after HIFU failure, interrupted before 11C choline PET and radiotherapy. Median prescribed dose was 71.4 Gy (range: 71.4-74.2 Gy) in 28 fractions. No radiation related major upper gastrointestinal (GI), rectal and GU toxicity were experienced. GU, acute grade 1 and grade 2 toxicities were recorded in 7/15 and 4/15 respectively; bowel acute grade 1 and grade 2 toxicities in 4/15 and 1/15; rectal acute grade 1 and grade 2 toxicities in 3/15 and 2/15 respectively. No grade 3 or greater acute or late toxicities occurred. Biochemical control was assessed in 12/15 (80%) patients. With a median follow up of 12 months, three out of 15 patients, with biochemical relapse, showed lymph-nodal recurrence. Our early clinical results and biochemical data confirm the feasibility and show a good tolerance of the 11C choline PET guided salvage radiation therapy after HIFU failure. The findings of low acute toxicity is encouraging, but longer follow-up is needed to assess late toxicity and definitive outcomes.
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Affiliation(s)
- Filippo Alongi
- Department of Radiotherapy, Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano-Milan, Italy.
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Kitajima K, Murphy RC, Nathan MA. Choline PET/CT for imaging prostate cancer: an update. Ann Nucl Med 2013; 27:581-91. [PMID: 23632880 DOI: 10.1007/s12149-013-0731-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 04/16/2013] [Indexed: 11/28/2022]
Abstract
Whole-body positron emission tomography/computed tomography (PET/CT) with [(11)C]- and [(18)F]-labeled choline derivates has emerged as a promising molecular imaging modality for the evaluation of prostate cancer. (11)C- and (18)F-choline PET/CT are used successfully for restaging prostate cancer in patients with biochemical recurrence of disease after definitive therapy, especially when the serum prostate-specific antigen level is >1.0 ng/mL. (11)C- and (18)F-choline PET/CT have more limited roles for the initial staging of prostate cancer and for the detection of tiny lymph node metastases due to the low spatial resolution inherent to PET. Overall, these modalities are most useful in patients with a high pre-test suspicion of metastatic disease. The following is a review of the current clinical roles of (11)C- and (18)F-choline PET/CT in the management of prostate cancer.
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Affiliation(s)
- Kazuhiro Kitajima
- Department of Radiology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
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Emonds KM, Swinnen JV, Lerut E, Koole M, Mortelmans L, Mottaghy FM. Evaluation of androgen-induced effects on the uptake of [18F]FDG, [11C]choline and [11C]acetate in an androgen-sensitive and androgen-independent prostate cancer xenograft model. EJNMMI Res 2013; 3:31. [PMID: 23618081 PMCID: PMC3640969 DOI: 10.1186/2191-219x-3-31] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 03/29/2013] [Indexed: 11/11/2022] Open
Abstract
Background Androgen deprivation (AD) is generally used as a first-line palliative treatment in prostate cancer (PCa) patients with rising prostate-specific antigen (PSA) after primary therapy. To acquire an accurate detection of tumour viability following AD with positron emission tomography (PET), an androgen-independent uptake of tracers would be advantageous. Several metabolic PET tracers are employed for detecting recurrent PCa. We evaluated the effect of AD on the uptake of 2-deoxy-2-[18F]fluoro-d-glucose ([18F]FDG), [11C]choline and [11C]acetate in vivo. Methods An [18F]FDG, [11C]choline and [11C]acetate baseline micro(μ)PET/μ computed tomography (CT) scan was subsequently performed in xenografts of androgen-sensitive (LAPC-4) and androgen-independent (22Rv1) tumours in nude mice. An untreated control group was compared to a surgical castration group, i.e. androgen-deprived group. μPET/μCT imaging with the above-mentioned tracers was repeated 5 days after the start of treatment. The percentage change of SUVmax and SUVmeanTH in the tumours was calculated. Results AD did not significantly affect the uptake of [18F]FDG and [11C]choline in LAPC-4 tumours as compared with the uptake of both tracers in untreated tumours. In control 22Rv1 tumours, [11C]choline and [18F]FDG uptake increased over time. However, compared with the uptake in control tumours, AD significantly decreased the uptake of [11C]choline and tended to decrease [18F]FDG uptake. [11C]acetate uptake remained unaffected by AD in both PCa xenograft models. Conclusions [18F]FDG and especially [11C]choline PET, which is currently used for the detection of recurrent PCa, could miss or underestimate the presence of local recurrent PCa following AD therapy. [11C]acetate uptake occurs independently of androgens and thus may be more favourable for detecting tumour viability during or following AD.
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Affiliation(s)
- Kimy M Emonds
- Department of Nuclear Medicine, University Hospitals Leuven, Leuven 3000, Belgium.
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The role of 11C-choline and 18F-fluorocholine positron emission tomography (PET) and PET/CT in prostate cancer: a systematic review and meta-analysis. Eur Urol 2013; 64:106-17. [PMID: 23628493 DOI: 10.1016/j.eururo.2013.04.019] [Citation(s) in RCA: 255] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 04/10/2013] [Indexed: 01/28/2023]
Abstract
CONTEXT The role of positron emission tomography (PET) and PET/computed tomography (PET/CT) in prostate cancer (PCa) imaging is still debated, although guidelines for their use have emerged over the last few years. OBJECTIVE To systematically review and conduct a meta-analysis of the available evidence of PET and PET/CT using 11C-choline and 18F-fluorocholine as tracers in imaging PCa patients in staging and restaging settings. EVIDENCE ACQUISITION PubMed, Embase, and Web of Science (by citation of reference) were searched. Reference lists of review articles and included articles were checked to complement electronic searches. EVIDENCE SYNTHESIS In staging patients with proven but untreated PCa, the results of the meta-analysis on a per-patient basis (10 studies, n = 637) showed pooled sensitivity, specificity, and diagnostic odds ratio (DOR) of 84% (95% confidence interval [CI], 68-93%), 79% (95% CI, 53-93%), and 20.4 (95% CI, 9.9-42.0), respectively. The positive and negative likelihood ratios were 4.02 (95% CI, 1.73-9.31) and 0.20 (95% CI, 0.11-0.37), respectively. On a per-lesion basis (11 studies, n = 5117), these values were 66% (95% CI, 56-75%), 92% (95% CI, 78-97%), and 22.7 (95% CI, 8.9-58.0), respectively, for pooled sensitivity, specificity, and DOR; and 8.29 (95% CI, 3.05-22.54) and 0.36 (95% CI, 0.29-0.46), respectively, for positive and negative likelihood ratios. In restaging patients with biochemical failure after local treatment with curative intent, the meta-analysis results on a per-patient basis (12 studies, n = 1055) showed pooled sensitivity, specificity, and DOR of 85% (95% CI, 79-89%), 88% (95% CI, 73-95%), and 41.4 (95% CI, 19.7-86.8), respectively; the positive and negative likelihood ratios were 7.06 (95% CI, 3.06-16.27) and 0.17 (95% CI, 0.13-0.22), respectively. CONCLUSIONS PET and PET/CT imaging with 11C-choline and 18F-fluorocholine in restaging of patients with biochemical failure after local treatment for PCa might help guide further treatment decisions. In staging of patients with proven but untreated, high-risk PCa, there is limited but promising evidence warranting further studies. However, the current evidence shows crucial limitations in terms of its applicability in common clinical scenarios.
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Brogsitter C, Zöphel K, Kotzerke J. 18F-Choline, 11C-choline and 11C-acetate PET/CT: comparative analysis for imaging prostate cancer patients. Eur J Nucl Med Mol Imaging 2013; 40 Suppl 1:S18-27. [PMID: 23579863 DOI: 10.1007/s00259-013-2358-2] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 01/24/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Claudia Brogsitter
- Department of Nuclear Medicine, Carl Gustav Carus Medical School, University of Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
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Dost RJ, Glaudemans AWJM, Breeuwsma AJ, de Jong IJ. Influence of androgen deprivation therapy on choline PET/CT in recurrent prostate cancer. Eur J Nucl Med Mol Imaging 2013; 40 Suppl 1:S41-7. [PMID: 23564037 DOI: 10.1007/s00259-013-2398-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 03/12/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE Recurrent prostate cancer is usually treated by combining radiotherapy and androgen deprivation therapy. To stage the cancer, choline positron emission tomography (PET)/CT can be performed. It is generally thought that androgen deprivation therapy does not influence choline PET/CT. In this article we focus on the molecular backgrounds of choline and androgens, and the results of preclinical and clinical studies performed using PET/CT. METHODS Using PubMed, we looked for the relevant articles about androgen deprivation therapy and choline PET/CT. RESULTS During ADT, a tendency of decreased uptake of choline in prostate cancer was observed, in particular in hormone-naïve patients. CONCLUSION We conclude that in order to prevent false-negative choline PET/CT scans androgen deprivation should be withheld prior to scanning, especially in hormone-naïve patients.
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Affiliation(s)
- Rutger J Dost
- Department of Urology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
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Beheshti M, Haim S, Zakavi R, Steinmair M, Waldenberger P, Kunit T, Nader M, Langsteger W, Loidl W. Impact of 18F-Choline PET/CT in Prostate Cancer Patients with Biochemical Recurrence: Influence of Androgen Deprivation Therapy and Correlation with PSA Kinetics. J Nucl Med 2013; 54:833-40. [DOI: 10.2967/jnumed.112.110148] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
The diagnostic approach to prostate cancer is still a big challenge for the treating physician. Regarding an individualized and risk-adapted evaluation of different therapeutic options, precise diagnostic tools are crucial to accurately distinguish between localized and advanced prostate cancer. Imaging of advanced prostate cancer is currently changing due to numerous technical innovations. While choline-based hybrid positron emission tomography-computed tomography (PET/CT) has been established as an important diagnostic tool in clinical imaging of advanced prostate cancer, well-investigated methods, such as magnetic resonance imaging (MRI) and bone scintigraphy are currently expanding the diagnostic potential due to technical improvements. The specific use of imaging for advanced prostate cancer may help to offer the patient a well-tailored oncologic therapy. Further research is needed to evaluate whether this individualized therapy can consistently improve the prognosis of patients suffering from advanced prostate cancer.
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Lu G, Maresca KP, Hillier SM, Zimmerman CN, Eckelman WC, Joyal JL, Babich JW. Synthesis and SAR of 99mTc/Re-labeled small molecule prostate specific membrane antigen inhibitors with novel polar chelates. Bioorg Med Chem Lett 2013; 23:1557-63. [DOI: 10.1016/j.bmcl.2012.09.014] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 09/04/2012] [Indexed: 10/27/2022]
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High-resolution optical molecular imaging of changes in choline metabolism in oral neoplasia. Transl Oncol 2013; 6:33-41. [PMID: 23418615 DOI: 10.1593/tlo.12289] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 12/14/2012] [Accepted: 12/18/2012] [Indexed: 12/20/2022] Open
Abstract
This study was aimed at developing an optical molecular imaging approach to measure differences in uptake and intracellular retention of choline in clinically isolated tissue biopsies from head and neck cancer patients. An optically detectable analogue of choline (propargyl choline) was synthesized and evaluated in 2D and 3D models and clinically isolated paired biopsies (n = 22 biopsies). Fluorescence contrast between clinically abnormal and normal tissues based on uptake and intracellular retention of propargyl choline was measured and correlated with pathologic diagnosis. Results in 2D and 3D models demonstrated a rapid uptake of propargyl choline in cancer cells, uniform permeation in tissue models, and specific detection of intracellular entrapped propargyl choline using the click chemistry reaction with an azide-modified Alexa 488 dye. Fluorescence imaging measurements following topical delivery of propargyl choline in clinically isolated biopsies showed that the mean fluorescence intensity (MFI) of neoplastic tissues was four-fold to five-fold higher than the MFI of clinically and pathologically normal samples. This difference in fluorescence contrast was measured on the basis of comparison of paired biopsy sets isolated from individual patients as well as comparison of clinically abnormal and normal biopsies independent of anatomic locations in the head and neck cavity and across diverse patients. In conclusion, a novel imaging approach based on monoalkyne-modified choline was developed and validated using cell and tissue models. Results in clinically isolated tissue biopsies demonstrate a significant fluorescent contrast between neoplastic and normal tissues and illustrate high specificity of the optical imaging approach.
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Kruse V, Cocquyt V, Borms M, Maes A, Van de Wiele C. Serum tumor markers and PET/CT imaging for tumor recurrence detection. Ann Nucl Med 2012; 27:97-104. [DOI: 10.1007/s12149-012-0664-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 10/22/2012] [Indexed: 12/12/2022]
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Radiotherapy after radical prostatectomy: immediate or early delayed? Strahlenther Onkol 2012; 188:1096-101. [DOI: 10.1007/s00066-012-0234-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 09/17/2012] [Indexed: 11/25/2022]
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Oprea-Lager DE, Vincent AD, van Moorselaar RJA, Gerritsen WR, van den Eertwegh AJM, Eriksson J, Boellaard R, Hoekstra OS. Dual-phase PET-CT to differentiate [18F]Fluoromethylcholine uptake in reactive and malignant lymph nodes in patients with prostate cancer. PLoS One 2012; 7:e48430. [PMID: 23119014 PMCID: PMC3485217 DOI: 10.1371/journal.pone.0048430] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 09/25/2012] [Indexed: 11/19/2022] Open
Abstract
Purpose To investigate whether time-trends of enhanced [18F]Fluoromethylcholine ([18F]FCH) in lymph nodes (LN) of prostate cancer (PCa) patients can help to discriminate reactive from malignant ones, and whether single time point standardized uptake value (SUV) measurements also suffice. Procedures 25 PCa patients with inguinal (presumed benign) and enlarged pelvic LN (presumed malignant) showing enhanced [18F]FCH uptake at dual-phase PET-CT were analyzed. Associations between LN status (benign versus malignant) and SUVmax and SUVmeanA50, determined at 2 min (early) and 30 min (late) post injection, were assessed. We considered two time-trends of [18F]FCH uptake: type A (SUV early > SUV late) and type B (SUV late ≥ SUV early). Histopathology and/or follow-up were used to confirm the assumption that LN with type A pattern are benign, and LN with type B pattern malignant. Results Analysis of 54 nodes showed that LN status, time-trends, and ‘late’ (30 min p.i.) SUVmax and SUVmeanA50 parameters were strongly associated (P<0.0001). SUVmax relative difference was the best LN status predictor. All but one inguinal LN showed a decreasing [18F]FCH uptake over time (pattern A), while 95% of the pelvic nodes presented a stable or increasing uptake (pattern B) type. Conclusions Time-trends of enhanced [18F]FCH uptake can help to characterize lymph nodes in prostate cancer patients. Single time-point SUV measurements, 30 min p.i., may be a reasonable alternative for predicting benign versus malignant status of lymph nodes, but this remains to be validated in non-enlarged pelvic lymph nodes.
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Affiliation(s)
- Daniela E Oprea-Lager
- Department of Nuclear Medicine and PET Research, VU University Medical Center, Amsterdam, The Netherlands.
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Operational characteristics of (11)c-choline positron emission tomography/computerized tomography for prostate cancer with biochemical recurrence after initial treatment. J Urol 2012; 189:1308-13. [PMID: 23123372 DOI: 10.1016/j.juro.2012.10.069] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 10/22/2012] [Indexed: 11/21/2022]
Abstract
PURPOSE We examined the performance of (11)C-choline positron emission tomography/computerized tomography for its ability to delineate prostate cancer distribution and extent after initial therapy. MATERIALS AND METHODS A consecutive series retrospective review was performed of all patients with prostate cancer who were evaluated using (11)C-choline positron emission tomography/computerized tomography from September 2007 to November 2010 at the Mayo Clinic. Statistical analysis was performed to determine the sensitivity, specificity, positive predictive value, negative predictive value and prostate specific antigen threshold for the detection of recurrent lesions. RESULTS In the study period 176 patients with biochemical recurrence after primary treatment failure underwent (11)C-choline positron emission tomography/computerized tomography. Using patient based analysis (11)C-choline positron emission tomography yielded a sensitivity, specificity, positive predictive value and negative predictive value of 93%, 76%, 91% and 81%, respectively. Of the 176 positron emission tomography/computerized tomography scans performed 56 (32%) were deemed clinically useful as defined by the ability to identify lesions not delineated using conventional imaging, thereby prompting changes in clinical management. The optimal prostate specific antigen for lesion detection was 2.0 ng/ml. On multivariate analysis prostate specific antigen at positron emission tomography (HR 1.37, p = 0.04) and clinical stage at initial diagnosis of prostate cancer (HR 5.19, p = 0.0035) were significant predictors of positive (11)C-choline positron emission tomography/computerized tomography. CONCLUSIONS (11)C-choline positron emission tomography/computerized tomography performs well in men with biochemical recurrence after primary treatment failure. The optimal prostate specific antigen value for lesion detection is approximately 2.0 ng/ml. We found that (11)C-choline positron emission tomography/computerized tomography substantially enhances the rate of prostate cancer lesion detection by approximately 32% beyond what can be garnered using conventional imaging techniques and at a lower prostate specific antigen value.
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Abstract
OBJECTIVE Recent advances in the fundamental understanding of the complex biology of prostate cancer have provided an increasing number of potential targets for imaging and treatment. The imaging evaluation of prostate cancer needs to be tailored to the various phases of this remarkably heterogeneous disease. CONCLUSION In this article, I review the current state of affairs on a range of PET radiotracers for potential use in the imaging evaluation of men with prostate cancer.
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Graham K, Lesche R, Gromov AV, Böhnke N, Schäfer M, Hassfeld J, Dinkelborg L, Kettschau G. Radiofluorinated derivatives of 2-(phosphonomethyl)pentanedioic acid as inhibitors of prostate specific membrane antigen (PSMA) for the imaging of prostate cancer. J Med Chem 2012; 55:9510-20. [PMID: 23025786 DOI: 10.1021/jm300710j] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
For prostate cancer, prostate specific membrane antigen (PSMA) has been identified as a diagnostic and therapeutic target. Fluorinated derivatives of 2-(phosphonomethyl)pentanedioic acid were designed and synthesized to explore whether this fluorine-substituent is tolerated in the pentanedioic acid moiety that is common to almost all PSMA targeting small molecule inhibitors. The binding affinities of the racemic and individual stereoisomers of 2-fluoro-4-(phosphonomethyl)pentanedioic acid were determined and showed that the introduction of fluorine was well tolerated. The radiosynthesis of the analogous 2-[(18)F]fluoro-4-(phosphonomethyl)pentanedioic acid was developed and evaluated in vivo with the PSMA positive LNCaP human prostate cancer cell. The biological results demonstrated specific binding of the tracer to PSMA positive tumors in mice. These results warrant the further evaluation of this class of compounds as radiolabeled tracers for the detection and staging of prostate cancer.
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Affiliation(s)
- Keith Graham
- Global Drug Discovery, Bayer HealthCare, Müllerstrasse 178, 13353, Berlin, Germany.
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Jilg CA, Rischke HC, Reske SN, Henne K, Grosu AL, Weber W, Drendel V, Schwardt M, Jandausch A, Schultze-Seemann W. Salvage lymph node dissection with adjuvant radiotherapy for nodal recurrence of prostate cancer. J Urol 2012; 188:2190-7. [PMID: 23083862 DOI: 10.1016/j.juro.2012.08.041] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Indexed: 11/17/2022]
Abstract
PURPOSE We evaluated the impact of salvage lymph node dissection with adjuvant radiotherapy in patients with nodal recurrence of prostate cancer. By default, nodal recurrence of prostate cancer is treated with palliative antihormonal therapy, which causes serious side effects and invariably leads to the development of hormone refractory disease. MATERIALS AND METHODS A total of 47 patients with nodal recurrence of prostate cancer based on evidence of (11)C-choline/(18)F-choline ((18)F-fluorethylcholine) positron emission tomography-computerized tomography underwent primary (2 of 52), secondary (45 of 52), tertiary (4 of 52) and quaternary (1 of 52) salvage lymph node dissection with histological confirmation. Of 52 salvage lymph node dissections 27 were followed by radiotherapy. Biochemical response was defined as a prostate specific antigen less than 0.2 ng/ml after salvage therapy. The Kaplan-Meier method, binary logistic regression and Cox regression were used to analyze survival as well as predictors of biochemical response and clinical progression. RESULTS Mean prostate specific antigen at salvage lymph node dissection was 11.1 ng/ml. A mean of 23.3 lymph nodes were removed per salvage lymph node dissection. Median followup was 35.5 months. Of 52 salvage lymph node dissections 24 resulted in complete biochemical response followed by 1-year biochemical recurrence-free survival of 71.8%. Gleason 6 or less (OR 7.58, p = 0.026), Gleason 7a/b (OR 5.91, p = 0.042) and N0 status at primary therapy (OR 8.01, p = 0.011) were identified as independent predictors of biochemical response. Gleason 8-10 (HR 3.5, p = 0.039) as a preoperative variable, retroperitoneal positive lymph nodes (HR 3.76, p = 0.021) and incomplete biochemical response (HR 4.0, p = 0.031) were identified as postoperative predictors of clinical progression. Clinical progression-free survival was 25.6% and cancer specific survival was 77.7% at 5 years. CONCLUSIONS Based on (11)C/(18)F-choline positron emission tomography-computerized tomography as a diagnostic tool, salvage lymph node dissection is feasible for the treatment of nodal recurrence of prostate cancer. Most patients experience biochemical recurrence after salvage lymph node dissection. However, a specific population has a lasting complete prostate specific antigen response.
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Affiliation(s)
- C A Jilg
- Department of Urology, Albert-Ludwigs University of Freiburg, Freiburg, Germany.
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