18F-fluorocholine PET/CT in patients with occult biochemical recurrence of prostate cancer: Detection rate, impact on management and adequacy of impact. A prospective multicentre study

Incidental Detection of Sarcomatoid Lung Cancer by [18F] Choline Positron Emission Tomography/Computed Tomography

A 79-year-old man treated for prostate cancer (PCa) in 2018 with concurrent hormone therapy and radical radiotherapy (RT) was given metastasis-directed RT because of skeletal progression of PCa in 2021. On [18F]-choline positron emission tomography/computed tomography (CT) for biochemical recurrence (prostate-specific antigen level: 4.96 ng/mL), he showed significant uptake in multiple skeletal lesions and focal uptake in a left lung nodule. CT-guided biopsy revealed a sarcomatoid lung carcinoma. This case confirms that histopathological evaluation is mandatory in the event of significant radiolabeled choline uptake in a single lung nodule.

ACR Appropriateness Criteria® Post-Treatment Follow-up of Prostate Cancer: 2022 Update

Prostate cancer has a wide spectrum ranging between low-grade localized disease and castrate-resistant metastatic disease. Although whole gland and systematic therapies result in cure in the majority of patients, recurrent and metastatic prostate cancer can still occur. Imaging approaches including anatomic, functional, and molecular modalities are continuously expanding. Currently, recurrent and metastatic prostate cancer is grouped in three major categories: 1) Clinical concern for residual or recurrent disease after radical prostatectomy, 2) Clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments, and 3) Metastatic prostate cancer treated by systemic therapy (androgen deprivation therapy, chemotherapy, immunotherapy). This document is a review of the current literature regarding imaging in these settings and the resulting recommendations for imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Narrative review of PET/CT performances at biochemical recurrence in prostate cancer after radical prostatectomy and impact on patient disease management: Revue narrative à propos des performances de la TEP/TDM en cas de récidive biochimique après prostatectomie radicale dans le cancer de la prostate et impact sur la prise en charge des patients

Patients treated by radical prostatectomy (RP) for localized prostate cancer (PCa) may experience biochemical recurrence (BCR) in approximately 30% of cases. Recently, advances in imaging modalities and in particular Positron-Emission Tomography with computed tomography (PET/CT) imaging allow for better detection and characterization of lesions outside the prostatic bed at recurrence. Thus, treatment at BCR can be significantly improved by a tailored strategy based on new generation imaging. A more precise and accurate staging of the disease at recurrence paves the way to more appropriate treatment, potentially translating into better survival outcomes of these patients. This review therefore highlights the interest of PET/CT at the time of BCR, its superiority over standard imaging in terms of staging, and its impact on guiding the different therapeutic possibilities depending on the site, number, and volumes of recurrence. Indeed, we will discuss below about different strategies and their indications: salvage radiotherapy of the prostate bed, systemic therapies, stereotactic body radiotherapy and others therapeutical strategies. The various innovative approaches based on PET/CT implementation are partly underway within protocol trials to prove their benefits on clinically meaningful endpoints. © 2022 Elsevier Masson SAS. All rights reserved.

The Role of PET-CT Imaging in Prostate Cancer

Prostate cancer is the commonest malignancy to affect men in the United Kingdom. Extraprostatic disease detection at staging and in the setting of biochemical recurrence is essential in determining treatment strategy. Conventional imaging including computed tomography and bone scintigraphy are limited in their ability to detect sites of loco-regional nodal and metastatic bone disease, particularly at clinically relevant low prostate-specific antigen levels. The use of positron emission tomography-computed tomography has helped overcome these deficiencies and is leading a paradigm shift in the management of prostate cancer using a wide range of radiopharmaceuticals. Their mechanisms of action, utility in both staging and biochemical recurrence, and comparative strengths and weaknesses will be covered in this article.

Usefulness of 18F-Choline Positron Emission Tomography - Computed Tomography in the therapeutic management of patients with biochemical recurrence of prostate adenocarcinoma treated with brachytherapy

OBJECTIVE

The objective of the study was to evaluate the usefulness of 18F-choline PET/CT in biochemically recurrent prostate cancer patients treated with brachytherapy, as well as to assess the changes in therapeutic management derived from its outcome.

MATERIAL AND METHODS

Retrospective study of 20 patients between 51 and 78 years old, with a history of prostate adenocarcinoma that had been treated with brachytherapy and presented biochemical recurrence (PSA 3.1-12 ng/ml) and staging tests (CT and bone scan) without alterations, were included. The findings visualized in the PET/CT scan with ¹⁸F-choline were correlated with the histopathology and/or the evolution of the PSA after therapy.

RESULTS

¹⁸F-choline PET/CT scan only detected local recurrence in 15 patients. Local and regional recurrences were seen in 4 patients, and 1 patient presented local and bone recurrence. Local recurrence detected in PET was confirmed by anatomopathological studies in 85% of the cases. In one patient, these findings (PET scan) turned out to be prostatitis, and it could not be confirmed in another patient. Of the cases with local and regional recurrence, local recurrence was histologically confirmed in 3 out of 4 patients. ¹⁸F-choline PET/CT changed the therapeutic management in 25% of the patients, discarding the initially planned salvage surgery in 3 cases, 1 radiotherapy and 1 brachytherapy.

CONCLUSION

¹⁸F-choline PET/CT could be a useful technique in the group of patients with biochemical recurrence after brachytherapy, providing locoregional and distant involvement findings which had not been detected with conventional imaging tests, thus determining a more adequate therapeutic management.

Effect of 18F-Fluciclovine Positron Emission Tomography on the Management of Patients With Recurrence of Prostate Cancer: Results From the FALCON Trial

PURPOSE

Early and accurate localization of lesions in patients with biochemical recurrence (BCR) of prostate cancer may guide salvage therapy decisions. The present study, 18F-Fluciclovine PET/CT in biochemicAL reCurrence Of Prostate caNcer (FALCON; NCT02578940), aimed to evaluate the effect of 18F-fluciclovine on management of men with BCR of prostate cancer.

METHODS AND MATERIALS

Men with a first episode of BCR after curative-intent primary therapy were enrolled at 6 UK sites. Patients underwent 18F-fluciclovine positron emission tomography/computed tomography (PET/CT) according to standardized procedures. Clinicians documented management plans before and after scanning, recording changes to treatment modality as major and changes within a modality as other. The primary outcome measure was record of a revised management plan postscan. Secondary endpoints were evaluation of optimal prostate specific antigen (PSA) threshold for detection, salvage treatment outcome assessment based on 18F-fluciclovine-involvement, and safety.

RESULTS

18F-Fluciclovine was well tolerated in the 104 scanned patients (median PSA = 0.79 ng/mL). Lesions were detected in 58 out of 104 (56%) patients. Detection was broadly proportional to PSA level; ≤1 ng/mL, 1 out of 3 of scans were positive, and 93% scans were positive at PSA >2.0 ng/mL. Sixty-six (64%) patients had a postscan management change (80% after a positive result). Major changes (43 out of 66; 65%) were salvage or systemic therapy to watchful waiting (16 out of 66; 24%); salvage therapy to systemic therapy (16 out of 66; 24%); and alternative changes to treatment modality (11 out of 66, 17%). The remaining 23 out of 66 (35%) management changes were modifications of the prescan plan: most (22 out of 66; 33%) were adjustments to planned brachytherapy/radiation therapy to include a 18F-fluciclovine-guided boost. Where 18F-fluciclovine guided salvage therapy, the PSA response rate was higher than when 18F-fluciclovine was not involved (15 out of 17 [88%] vs 28 out of 39 [72%]).

CONCLUSIONS

18F-Fluciclovine PET/CT located recurrence in the majority of men with BCR, frequently resulting in major management plan changes. Incorporating 18F-fluciclovine PET/CT into treatment planning may optimize targeting of recurrence sites and avoid futile salvage therapy.

Comparison of 18F-sodium fluoride PET/CT, 18F-fluorocholine PET/CT and diffusion-weighted MRI for the detection of bone metastases in recurrent prostate cancer: a cost-effectiveness analysis in France

Background

The diagnostic performance of ¹⁸F-sodium fluoride positron emission tomography/computed tomography (PET/CT) (NaF), ¹⁸F-fluorocholine PET/CT (FCH) and diffusion-weighted whole-body magnetic resonance imaging (DW-MRI) in detecting bone metastases in prostate cancer (PCa) patients with first biochemical recurrence (BCR) has already been published, but their cost-effectiveness in this indication have never been compared.

Methods

We performed trial-based and model-based economic evaluations. In the trial, PCa patients with first BCR after previous definitive treatment were prospectively included. Imaging readings were performed both on-site by local specialists and centrally by experts. The economic evaluation extrapolated the diagnostic performances of the imaging techniques using a combination of a decision tree and Markov model based on the natural history of PCa. The health states were non-metastatic and metastatic BCR, non-metastatic and metastatic castration-resistant prostate cancer and death. The state-transition probabilities and utilities associated with each health state were derived from the literature. Real costs were extracted from the National Cost Study of hospital costs and the social health insurance cost schedule.

Results

There was no significant difference in diagnostic performance among the 3 imaging modalities in detecting bone metastases. FCH was the most cost-effective imaging modality above a threshold incremental cost-effectiveness ratio of 3000€/QALY when imaging was interpreted by local specialists and 9000€/QALY when imaging was interpreted by experts.

Conclusions

FCH had a better incremental effect on QALY, independent of imaging reading and should be preferred for detecting bone metastases in patients with biochemical recurrence of prostate cancer.

Trial registration

NCT01501630. Registered 29 December 2011.

Imaging for Metastasis in Prostate Cancer: A Review of the Literature

Background: Initial staging and assessment of treatment activity in metastatic prostate cancer (PCa) patients is controversial. Indications for the various available imaging modalities are not well-established due to rapid advancements in imaging and treatment.

Methods: We conducted a critical literature review of the main imaging abnormalities that suggest a diagnosis of metastasis in localized and locally advanced PCa or in cases of biological relapse. We also assessed the role of the various imaging modalities available in routine clinical practice for the detection of metastases and response to treatment in metastatic PCa patients.

Results: In published clinical trials, the most commonly used imaging modalities for the detection and evaluation of therapeutic response are bone scan, abdominopelvic computed tomography (CT), and pelvic and bone magnetic resonance imaging (MRI). For the detection and follow-up of metastases during treatment, modern imaging techniques i.e., choline-positron emission tomography (PET), fluciclovine-PET, or Prostate-specific membrane antigen (PSMA)-PET provide better sensitivity and specificity. This is particularly the case of fluciclovine-PET and PSMA-PET in cases of biochemical recurrence with low values of prostate specific antigen.

Conclusions: In routine clinical practice, conventional imaging still have a role, and communication between imagers and clinicians should be encouraged. Present and future clinical trials should use modern imaging methods to clarify their usage.

Qualitative and quantitative reproducibility of [18]fluoromethycholine PET/computed tomography in prostate cancer

BACKGROUND

Recurrence occurs in more than 50% of prostate cancer. To be effective, treatments require precise localization of tumor cells. [F]fluoromethylcholine ([18F]FCH) PET/computed tomography (CT) is currently used to restage disease in cases of biochemical relapse. To be used for therapy response as has been suggested, repeatability limits of PET derived indices need to be established.

OBJECTIVE

The aim of our study was to prospectively assess the qualitative and quantitative reproducibility [18F]FCH PET/CT in prostate cancer.

METHODS

Patients with histologically proven prostate cancer referred for initial staging or restaging were prospectively included. All patients underwent two [18F]FCH PET/CTs in the same conditions within a maximum of 3 weeks' time. We studied the repeatability of the visual report and the repeatability of SUVmax and its evolution over the acquisition time in lesions, liver and vascular background. Statistical analysis was performed using the Bland-Altman approach.

RESULTS

Twenty-one patients were included. Reporting repeatability was excellent with 97.8% of concordance. Mean repeatability of SUVmax considering all times and all lesions was 2.2% ± 20. Evolution of SUVmax was unpredictable, either increasing or decreasing over the acquisition time, both for lesions and for physiological activity.

CONCLUSION

Our study demonstrated that visual report of [18F]FCH PET/CT was very reproducible and that the repeatability limits of SUVmax was similar to those of other PET radiotracers. An SUVmax difference of more than 40% should be considered as representing a treatment response effect. Change of SUVmax during the acquisition time varied and should not be considered as an interpretation criterion.

Effect of positive carbon-11-choline PET/CT results in the therapeutic management of prostate cancer biochemical relapse

OBJECTIVE

Carbon-11-(C)-choline PET/computed tomography (CT) has shown good results in re-staging of prostate cancer (PCa) with raised serum levels of prostate-specific antigen. Our aim was to evaluate the effect of positive C-choline PET/CT results in the therapeutic management of patients with PCa with biochemical relapse (BR) after curative intention treatment.

PATIENTS AND METHODS

A total of 112 patients with PCa BR and positive C-choline PET/CT were retrospectively evaluated. PET/CT was acquired 20 min after intravenous administration of 555-740 MBq of C-choline. The therapeutic management after C-choline PET/CT was obtained from the clinical records. The minimum follow-up time was 18 months.

RESULTS

In 80 (71.4%) of 112 patients, C-choline PET/CT showed local recurrence of PCa; in 17 (15.2%) patients, distant recurrence; and in 15 (13.4%) patients, local plus distant recurrence. A second malignancy was detected in five (4.5%) patients. The planned therapeutic management was changed as per positive C-choline PET/CT result in 74 (66.1%) patients and were treated as follows: 31 (27.7%) patients with HT, combined with other treatments in eight (7.1%), 17 (15.2%) with BT, 13 (11.6%) with external beam radiotherapy, one (0.9%) with RP, and four (3.6%) with chemotherapy. Treatment approach was not modified in 37 (33%) patients. No data was available from one (0.9%) patient.

CONCLUSION

Positive C-choline PET/CT result had an important effect in the therapeutic management of patients with PCa and BR, leading to a change in the planned approach in two (66.1%) out of three patients. In addition, in 4.5% of the patients, the C-choline PET/CT allowed the detection of a second malignancy.

Impact of sodium 18F-fluoride PET/CT, 18F-fluorocholine PET/CT and whole-body diffusion-weighted MRI on the management of patients with prostate cancer suspicious for metastasis: a prospective multicentre study

PURPOSE

To compare the impact of 18F-sodium-fluoride (NaF) PET/CT, 18F-fluorocholine (FCH) PET/CT and diffusion-weighted whole-body MRI (DW-MRI) on the management of patients with prostate cancer (PCa) suspicious for distant metastasis.

METHODS

Prostate cancer patients were prospectively included between December 2011 and August 2014 and benefited from these three whole-body imaging (WBI) modalities within 1 month in addition to the standard PCa workup. Management was prospectively decided by clinicians during two multidisciplinary meetings, before and after the whole-body imaging workup. Rates of induced changes of whole-body imaging modalities were compared by Cochran's Q test.

RESULTS

One-hundred-one patients (27 at staging, 59 at first biochemical recurrence (BCR) and 15 at first episode of rising serum level of prostate-specific antigen during androgen-deprivation therapy) were included. The overall rate of management changes was 52%: 29% as a consequence of WBI, higher for FCH-PET/CT than for NaF-PET/CT or DW-MRI (p < 0.0001) and highest (41%) for FCH-PET/CT at BCR. Actual management was adequate in all patients but two.

CONCLUSIONS

Whole-body imaging induced a change in management in approximately a third of PCa patients suspicious for metastasis. The impact rate was determined to be greatest at first BCR using FCH-PET/CT. NaF-PET/CT and DW-MRI seemed less useful in this context.