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Friedrich NA, Gu L, Waller J, De Hoedt AM, Klaassen Z, Freedland SJ. Real-world evidence of 18F-fluciclovine Positron emission tomography/computed tomography performance for recurrent prostate cancer in the Veterans Affairs Health System. Prostate 2024; 84:1336-1343. [PMID: 39031050 DOI: 10.1002/pros.24770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 06/21/2024] [Accepted: 07/09/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND There are no population-level studies assessing 18F-fluciclovine (fluciclovine) utilization of Positron emission tomography/computed tomography (PET/CT) for biochemically recurrent prostate cancer (PC). We assessed fluciclovine PET/CT in the Veterans Affairs Health Care System. METHODS Of 1153 men with claims suggesting receipt of fluciclovine PET/CT, we randomly reviewed charts of 300 who indeed underwent fluciclovine PET/CT. The primary outcome was fluciclovine PET/CT result (positive or negative). Comparison among groups stratified by androgen deprivation therapy (ADT) (yes vs. no) and prostate-specific antigen (PSA) (≤1 vs. >1 ng/mL) at imaging were performed. Logistic regression tested associations between PSA, ADT receipt, and race with fluciclovine PET/CT positive imaging. RESULTS Fluciclovine PET/CT positivity rate was 33% for patients with PSA 0-0.5 ng/mL, 21% for >0.5-1.0, 54% for >1.0-2.0, and 66% for >2.0 (p < 0.01). A 59% positivity rate ocurred in patients treated with concurrent ADT versus 37% in those not on ADT (p < 0.01). White were more likely to have a positive scan versus Black patients (55% vs. 38%; p = 0.02). Patients whose primary treatment was radical prostatectomy had a lower positivity rate (33%) versus those treated with radiotherapy (55%) (p < 0.001). On multivariable logistic regression, PSA > 1 ng/mL (all men odds ratio [OR]: 4.06, 95% confidence interval [CI]: 2.07-7.96; men on ADT only OR: 4.42, 95% CI: 1.73-11.26) and use of ADT (OR: 3.94, 95% CI: 1.32-11.75), and White (all men OR: 2.22, 95% CI: 1.20-4.17) predicted positive fluciclovine PET/CT. CONCLUSION This real-world study assessing 18F-fluciclovine PET/CT performance in an equal access health care system confirms higher detection rates than traditional imaging methods, but positivity is highly influenced by PSA at time of imaging. Additionally, patients currently receiving ADT have at least four times higher likelihood of a positive scan, showing that scan positivity isn't negatively affected by ADT status in this study. Finally, White men were more likely to have a positive scan, the reasons for which should be explored in future studies.
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Affiliation(s)
- Nadine A Friedrich
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lin Gu
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Justin Waller
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Amanda M De Hoedt
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Zachary Klaassen
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Division of Urology, Department of Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
- Georgia Cancer Center, Augusta, Georgia, USA
| | - Stephen J Freedland
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
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Wang T, Lei Y, Schreibmann E, Roper J, Liu T, Schuster DM, Jani AB, Yang X. Lesion segmentation on 18F-fluciclovine PET/CT images using deep learning. Front Oncol 2023; 13:1274803. [PMID: 38156106 PMCID: PMC10753832 DOI: 10.3389/fonc.2023.1274803] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
Background and purpose A novel radiotracer, 18F-fluciclovine (anti-3-18F-FACBC), has been demonstrated to be associated with significantly improved survival when it is used in PET/CT imaging to guide postprostatectomy salvage radiotherapy for prostate cancer. We aimed to investigate the feasibility of using a deep learning method to automatically detect and segment lesions on 18F-fluciclovine PET/CT images. Materials and methods We retrospectively identified 84 patients who are enrolled in Arm B of the Emory Molecular Prostate Imaging for Radiotherapy Enhancement (EMPIRE-1) trial. All 84 patients had prostate adenocarcinoma and underwent prostatectomy and 18F-fluciclovine PET/CT imaging with lesions identified and delineated by physicians. Three different neural networks with increasing levels of complexity (U-net, Cascaded U-net, and a cascaded detection segmentation network) were trained and tested on the 84 patients with a fivefold cross-validation strategy and a hold-out test, using manual contours as the ground truth. We also investigated using both PET and CT or using PET only as input to the neural network. Dice similarity coefficient (DSC), 95th percentile Hausdorff distance (HD95), center-of-mass distance (CMD), and volume difference (VD) were used to quantify the quality of segmentation results against ground truth contours provided by physicians. Results All three deep learning methods were able to detect 144/155 lesions and 153/155 lesions successfully when PET+CT and PET only, respectively, served as input. Quantitative results demonstrated that the neural network with the best performance was able to segment lesions with an average DSC of 0.68 ± 0.15 and HD95 of 4 ± 2 mm. The center of mass of the segmented contours deviated from physician contours by approximately 2 mm on average, and the volume difference was less than 1 cc. The novel network proposed by us achieves the best performance compared to current networks. The addition of CT as input to the neural network contributed to more cases of failure (DSC = 0), and among those cases of DSC > 0, it was shown to produce no statistically significant difference with the use of only PET as input for our proposed method. Conclusion Quantitative results demonstrated the feasibility of the deep learning methods in automatically segmenting lesions on 18F-fluciclovine PET/CT images. This indicates the great potential of 18F-fluciclovine PET/CT combined with deep learning for providing a second check in identifying lesions as well as saving time and effort for physicians in contouring.
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Affiliation(s)
- Tonghe Wang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Yang Lei
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Eduard Schreibmann
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Justin Roper
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Tian Liu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - David M. Schuster
- Department of Radiology and Imaging Science and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Ashesh B. Jani
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
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Lawal IO, Jani AB, Adediran OA, Goyal S, Abiodun-Ojo OA, Dhere VR, Marcus CV, Joshi SS, Master VA, Patel PR, Goodman M, Shelton JW, Kucuk O, Hershatter B, Fielder B, Halkar RK, Schuster DM. Differences in Failure-Free Survival After Salvage Radiotherapy Guided by Conventional Imaging Versus 18F-Fluciclovine PET/CT in Postprostatectomy Patients: A Post Hoc Substratification Analysis of the EMPIRE-1 Trial. J Nucl Med 2023; 64:586-591. [PMID: 36328489 PMCID: PMC10071787 DOI: 10.2967/jnumed.122.264832] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022] Open
Abstract
The EMPIRE-1 (Emory Molecular Prostate Imaging for Radiotherapy Enhancement 1) trial reported a survival advantage in recurrent prostate cancer salvage radiotherapy (SRT) guided by 18F-fluciclovine PET/CT versus conventional imaging. We performed a post hoc analysis of the EMPIRE-1 cohort stratified by protocol-specified criteria, comparing failure-free survival (FFS) between study arms. Methods: EMPIRE-1 randomized patients to SRT planning via either conventional imaging only (bone scanning plus abdominopelvic CT or MRI) (arm A) or conventional imaging plus 18F-fluciclovine PET/CT (arm B). Randomization was stratified by prostate-specific antigen (PSA) level (<2.0 vs. ≥ 2.0 ng/mL), adverse pathology, and androgen-deprivation therapy (ADT) intent. We subdivided patients in each arm using the randomization stratification criteria and compared FFS between patient subgroups across study arms. Results: Eighty-one and 76 patients received per-protocol SRT in study arms A and B, respectively. The median follow-up was 3.5 y (95% CI, 3.0-4.0). FFS was 63.0% and 51.2% at 36 and 48 mo, respectively, in arm A and 75.5% at both 36 and 48 mo in arm B. Among patients with a PSA of less than 2 ng/mL (mean, 0.42 ± 0.42 ng/mL), significantly higher FFS was seen in arm B than arm A at 36 mo (83.2% [95% CI, 70.0-91.0] vs. 66.5% [95% CI, 51.6-77.8], P < 0.001) and 48 mo (83.2% [95% CI, 70.0-91.0] vs. 56.2% [95% CI, 40.5-69.2], P < 0.001). No significant difference in FFS between study arms in patients with a PSA of at least 2 ng/mL was observed. Among patients with adverse pathology, significantly higher FFS was seen in arm B than arm A at 48 mo (68.9% [95% CI, 52.1-80.8] vs. 42.8% [95% CI, 26.2-58.3], P < 0.001) though not at the 36-mo follow-up. FFS was higher in patients without adverse pathology in arm B versus arm A (90.2% [95% CI, 65.9-97.5] vs. 73.1% [95% CI, 42.9-89.0], P = 0.006) at both 36 and 48 mo. Patients in whom ADT was intended in arm B had higher FFS than those in arm A, with the difference reaching statistical significance at 48 mo (65.2% [95% CI, 40.3-81.7] vs. 29.1 [95% CI, 6.5-57.2], P < 0.001). Patients without ADT intent in arm B had significantly higher FFS than patients in arm A at 36 mo (80.7% [95% CI, 64.9-90.0] vs. 68.0% [95% CI, 51.1-80.2]) and 48 mo (80.7% [95% CI, 64.9-90.0] vs. 58.6% [95% CI, 41.0-72.6]). Conclusion: The survival advantage due to the addition of 18F-fluciclovine PET/CT to SRT planning is maintained regardless of the presence of adverse pathology or ADT intent. Including 18F-fluciclovine PET/CT to SRT leads to survival benefits in patients with a PSA of less than 2 ng/mL but not in patients with a PSA of 2 ng/mL or higher.
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Affiliation(s)
- Ismaheel O Lawal
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia;
- Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa
| | - Ashesh B Jani
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Omotayo A Adediran
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Subir Goyal
- Biostatics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | | | - Vishal R Dhere
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Charles V Marcus
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Shreyas S Joshi
- Department of Urology, Emory University, Atlanta, Georgia; and
| | - Viraj A Master
- Department of Urology, Emory University, Atlanta, Georgia; and
| | - Pretesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Mark Goodman
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Joseph W Shelton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Omer Kucuk
- Department of Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Bruce Hershatter
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Bridget Fielder
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Raghuveer K Halkar
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - David M Schuster
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
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Nabian N, Ghalehtaki R, Couñago F. Necessity of Pelvic Lymph Node Irradiation in Patients with Recurrent Prostate Cancer after Radical Prostatectomy in the PSMA PET/CT Era: A Narrative Review. Biomedicines 2022; 11:biomedicines11010038. [PMID: 36672547 PMCID: PMC9855373 DOI: 10.3390/biomedicines11010038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 12/28/2022] Open
Abstract
The main prostate cancer (PCa) treatments include surgery or radiotherapy (with or without ADT). However, none of the suggested treatments eliminates the risk of lymph node metastases. Conventional imaging methods, including MRI and CT scanning, are not sensitive enough for the diagnosis of lymph node metastases; however, the novel imaging method, PSMA PET/CT scanning, has provided valuable information about the pelvic LN involvement in patients with recurrent PCa (RPCa) after radical prostatectomy. The high sensitivity and negative predictive value enable accurate N staging in PCa patients. In this narrative review, we summarize the evidence on the treatment and extent of radiation in prostate-only or whole-pelvis radiation in patients with positive and negative LN involvement on PSMA PET/CT scans.
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Affiliation(s)
- Naeim Nabian
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran P.O. Box 1419733141, Iran
- Department of Radiation Oncology, Cancer Institute, Tehran University of Medical Sciences, Tehran P.O. Box 1419733141, Iran
| | - Reza Ghalehtaki
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran P.O. Box 1419733141, Iran
- Department of Radiation Oncology, Cancer Institute, Tehran University of Medical Sciences, Tehran P.O. Box 1419733141, Iran
- Correspondence:
| | - Felipe Couñago
- Department of Radiation Oncology, San Francisco de Asís and La Milagrosa Hospitals, GenesisCare, 28010 Madrid, Spain
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Payne H, Bomanji J, Bottomley D, Scarsbrook AF, Teoh EJ. Impact of 18F-fluciclovine PET/CT on salvage radiotherapy plans for men with recurrence of prostate cancer postradical prostatectomy. Nucl Med Commun 2022; 43:201-211. [PMID: 34669678 PMCID: PMC8754096 DOI: 10.1097/mnm.0000000000001501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/04/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Imaging options to localize biochemical recurrence (BCR) of prostate cancer after radical prostatectomy (RP) are limited, especially at low prostate-specific antigen (PSA) levels. The FALCON study evaluated the impact of 18F-fluciclovine PET/CT on management plans for patients with BCR. Here, we evaluate salvage radiotherapy decisions in patients post-RP. METHODS We conducted a subgroup analysis of post-RP patients enrolled in FALCON who had a prescan plan for salvage radiotherapy (± androgen-deprivation therapy). Patients' treatment plans post-18F-fluciclovine PET/CT were compared with their prescan plans. Fisher exact test was used to determine the impact of PSA and Gleason sum on positivity and anatomical patterns of uptake. RESULTS Sixty-five (63%) FALCON patients had undergone RP. Of these, 62 (median PSA, 0.32 ng/mL) had a prescan plan for salvage radiotherapy. Twenty-one (34%) had 18F-fluciclovine-avid lesions. Disease was confined to the prostate bed in 11 patients (52%) and to the pelvis in a further 5 (24%), while 5 (24%) had extrapelvic findings. Trends towards more disseminated disease with increasing PSA or Gleason sum were observed but did not reach statistical significance. Postscan, 25 (40%) patients had a management change; 17 (68%) were changed to the treatment modality (8 to systemic therapy, 8 to active surveillance, 1 other) and 8 (32%) were radiotherapy field modifications. CONCLUSIONS Incorporating 18F-fluciclovine PET/CT into treatment planning may help identify patients suitable for salvage radiotherapy, help augment planned radiotherapy to better target lesions and support the clinician to optimise patient management.
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Affiliation(s)
- Heather Payne
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London
| | - Jamshed Bomanji
- Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London
| | | | | | - Eugene J. Teoh
- Departments of Radiology and Nuclear Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK (at the time of study conduct)
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Galgano SJ, McDonald AM, Rais-Bahrami S, Porter KK, Choudhary G, Burgan C, Bhambhvani P, Nix JW, Morgan DE, Li Y, Thomas JV, McConathy J. Utility of 18F-Fluciclovine PET/MRI for Staging Newly Diagnosed High-Risk Prostate Cancer and Evaluating Response to Initial Androgen Deprivation Therapy: A Prospective Single-Arm Pilot Study. AJR Am J Roentgenol 2021; 217:720-729. [PMID: 33052718 PMCID: PMC9170127 DOI: 10.2214/ajr.20.24509] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND. Despite advances in prostate cancer treatment, rates of biochemical recurrence remain high, relating to lack of detection of small-volume metastatic disease using conventional imaging for initial staging. OBJECTIVE. The purpose of this study was to assess the potential use of 18F-fluciclovine PET/MRI for initial staging of high-risk prostate cancer and evaluating response to androgen deprivation therapy (ADT). METHODS. This prospective clinical trial enrolled 14 men with newly diagnosed high-risk prostate cancer and negative or equivocal conventional staging imaging for metastatic disease between January 2018 and February 2019. All patients underwent pretreatment 18F-fluciclovine PET/MRI including multiparametric prostate MRI; 12 underwent 18F-fluciclovine PET/MRI after surgery or between ADT and radiotherapy. Confidence in identification of the primary intraprostatic lesion and nodal metastases was independently rated on a 0-3 Likert scale by three readers with nuclear medicine experience for 18F-fluciclovine PET/MRI and three readers with abdominal imaging experience for MRI alone. Findings scored as 2 or 3 by at least two readers of a given modality were considered positive. A single reader measured SUVmean, SUVmax, and volume of the MRI-defined intraprostatic lesion and SUVmax of suspicious lymph nodes on PET before and after initiation of ADT. Changes in SUV were analyzed using nonparametric Wilcox-on signed-rank tests. RESULTS. The biopsy-proven lesion in the prostate gland was accurately identified in all 14 patients on both MRI and 18F-fluciclovine PET/MRI. Suspected nodal metastases were detected in three patients on MRI and seven patients on 18F-fluciclovine PET/MRI. After ADT, all patients showed decreased activity within the intraprostatic lesion and/or all suspicious lymph nodes. The primary lesion SUVmean was 4.5 ± 1.1 (range, 2.7-6.5) before treatment and 2.4 ± 1.1 (range, 0.0-3.6) after initiation of ADT (p = .008). For suspicious lymph nodes, the pretreatment SUVmax was 5.5 ± 3.7 (range, 2.8-12.7) and the post-treatment SUVmax was 2.8 ± 1.4 (range, 1.4-5.5) (p = .03). CONCLUSION.18F-labeled fluciclovine PET/MRI shows potential utility in initial staging of high-risk prostate cancer and in evaluating response to ADT. CLINICAL IMPACT. Given the FDA approval and widespread availability of 18F-fluciclovine, the findings could have an impact in the immediate future in guiding initial management of patients with prostate cancer. TRIAL REGISTRATION. ClinicalTrials.gov NCT03264456.
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Affiliation(s)
- Samuel J Galgano
- Department of Radiology, University of Alabama at Birmingham, 619 19th St S, JT N325, Birmingham, AL 35249
- O'Neal Comprehensive Cancer Center at UAB, University of Alabama at Birmingham, Birmingham, AL
| | - Andrew M McDonald
- O'Neal Comprehensive Cancer Center at UAB, University of Alabama at Birmingham, Birmingham, AL
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Soroush Rais-Bahrami
- Department of Radiology, University of Alabama at Birmingham, 619 19 St S, JT N325, Birmingham, AL 35249
- O'Neal Comprehensive Cancer Center at UAB, University of Alabama at Birmingham, Birmingham, AL
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL
| | - Kristin K Porter
- Department of Radiology, University of Alabama at Birmingham, 619 19 St S, JT N325, Birmingham, AL 35249
| | - Gagandeep Choudhary
- Department of Radiology, University of Alabama at Birmingham, 619 19 St S, JT N325, Birmingham, AL 35249
| | - Constantine Burgan
- Department of Radiology, University of Alabama at Birmingham, 619 19 St S, JT N325, Birmingham, AL 35249
| | - Pradeep Bhambhvani
- Department of Radiology, University of Alabama at Birmingham, 619 19 St S, JT N325, Birmingham, AL 35249
| | - Jeffrey W Nix
- O'Neal Comprehensive Cancer Center at UAB, University of Alabama at Birmingham, Birmingham, AL
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL
| | - Desiree E Morgan
- Department of Radiology, University of Alabama at Birmingham, 619 19 St S, JT N325, Birmingham, AL 35249
- O'Neal Comprehensive Cancer Center at UAB, University of Alabama at Birmingham, Birmingham, AL
| | - Yufeng Li
- Department of Radiology, University of Alabama at Birmingham, 619 19 St S, JT N325, Birmingham, AL 35249
- O'Neal Comprehensive Cancer Center at UAB, University of Alabama at Birmingham, Birmingham, AL
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - John V Thomas
- Department of Radiology, University of Alabama at Birmingham, 619 19 St S, JT N325, Birmingham, AL 35249
| | - Jonathan McConathy
- Department of Radiology, University of Alabama at Birmingham, 619 19 St S, JT N325, Birmingham, AL 35249
- O'Neal Comprehensive Cancer Center at UAB, University of Alabama at Birmingham, Birmingham, AL
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Abiodun-Ojo OA, Jani AB, Akintayo AA, Akin-Akintayo OO, Odewole OA, Tade FI, Joshi SS, Master VA, Fielder B, Halkar RK, Zhang C, Goyal S, Goodman MM, Schuster DM. Salvage Radiotherapy Management Decisions in Postprostatectomy Patients with Recurrent Prostate Cancer Based on 18F-Fluciclovine PET/CT Guidance. J Nucl Med 2021; 62:1089-1096. [PMID: 33517323 PMCID: PMC8833876 DOI: 10.2967/jnumed.120.256784] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/14/2020] [Indexed: 11/16/2022] Open
Abstract
Imaging with novel PET radiotracers has significantly influenced radiotherapy decision making and radiation planning in patients with recurrent prostate cancer (PCa). The purpose of this analysis was to report the final results for management decision changes based on 18F-fluciclovine PET/CT findings and determine whether the decision change trend remained after completion of accrual. Methods: Patients with detectable prostate-specific antigen (PSA) after prostatectomy were randomized to undergo either conventional imaging (CI) only (arm A) or CI plus 18F-fluciclovine PET/CT (arm B) before radiotherapy. In arm B, positivity rates on CI and 18F-fluciclovine PET/CT for detection of recurrent PCa were determined. Final decisions on whether to offer radiotherapy and whether to include only the prostate bed or also the pelvis in the radiotherapy field were based on 18F-fluciclovine PET/CT findings. Radiotherapy decisions before and after 18F-fluciclovine PET/CT were compared. The statistical significance of decision changes was determined using the Clopper-Pearson (exact) binomial method. Prognostic factors were compared between patients with and without decision changes. Results: All 165 patients enrolled in the study had standard-of-care CI and were initially planned to receive radiotherapy. Sixty-three of 79 (79.7%) patients (median PSA, 0.33 ng/mL) who underwent 18F-fluciclovine PET/CT (arm B) had positive findings. 18F-Fluciclovine PET/CT had a significantly higher positivity rate than CI did for the whole body (79.7% vs. 13.9%; P < 0.001), prostate bed (69.6% vs. 5.1%; P < 0.001), and pelvic lymph nodes (38.0% vs. 10.1%; P < 0.001). Twenty-eight of 79 (35.4%) patients had the overall radiotherapy decision changed after 18F-fluciclovine PET/CT; in 4 of 79 (5.1%), the decision to use radiotherapy was withdrawn because of extrapelvic disease detected on 18F-fluciclovine PET/CT. In 24 of 75 (32.0%) patients with a final decision to undergo radiotherapy, the radiotherapy field was changed. Changes in overall radiotherapy decisions and radiotherapy fields were statistically significant (P < 0.001). Overall, the mean PSA at PET was significantly different between patients with and without radiotherapy decision changes (P = 0.033). Conclusion:18F-Fluciclovine PET/CT significantly altered salvage radiotherapy decisions in patients with recurrent PCa after prostatectomy. Further analysis to determine the impact of 18F-fluciclovine PET/CT guidance on clinical outcomes after radiotherapy is in progress.
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Affiliation(s)
| | - Ashesh B Jani
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Akinyemi A Akintayo
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | | | - Oluwaseun A Odewole
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Funmilayo I Tade
- Department of Radiology, Loyola University Medical Center, Maywood, Illinois
| | | | - Viraj A Master
- Department of Urology, Emory University, Atlanta, Georgia
| | - Bridget Fielder
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Raghuveer K Halkar
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Chao Zhang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Subir Goyal
- Department of Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia; and
| | - Mark M Goodman
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
- Emory University Center for Systems Imaging, Atlanta, Georgia
| | - David M Schuster
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
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8
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Baiomy A, Schellingerhout D, Chapin BF, Weinberg JS, Raza SM, Macapinlac H, Ravizzini G. Rate of incidental central nervous system meningioma detected in patients undergoing 18F-fluciclovine PET/CT imaging for evaluation of prostate cancer. Nucl Med Commun 2021; 42:755-762. [PMID: 33741867 DOI: 10.1097/mnm.0000000000001389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the rate of incidental detection of central nervous system (CNS) meningioma in patients undergoing 18F-fluciclovine PET/computed tomography (CT) imaging for the evaluation of prostate cancer. METHODS The reports of 850 18F-fluciclovine PET/CT scans in 566 patients with pathologically proven prostate cancer performed from April 2017 to July 2019, were retrospectively reviewed for the presence of CNS meningioma. RESULTS A total of 14 patients (2.8%) (age range: 54-82 years old) had abnormal focal intracranial 18F-fluciclovine uptake, all extra-axial in location (SUVmax range: 3.2-19.3). Two cases out of 14 (0.35%) were diagnosed as metastatic lesions. Twelve out of the 14 patients, had 18F-fluciclovine PET/CT imaging findings suspicious for CNS meningioma, 2 of them received another diagnosis on further imaging, and only 10 cases (2%) had the diagnosis of meningioma according to follow-up MRI and 18F-fluciclovine PET/CT. CONCLUSION Focal 18F-fluciclovine avid intracranial lesions incidentally detected in patients undergoing PET/CT imaging for prostate cancer are most often CNS meningiomas.
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Affiliation(s)
| | | | | | | | | | - Homer Macapinlac
- Department of Nuclear Medicine The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gregory Ravizzini
- Department of Nuclear Medicine The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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9
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Jani AB, Schreibmann E, Goyal S, Halkar R, Hershatter B, Rossi PJ, Shelton JW, Patel PR, Xu KM, Goodman M, Master VA, Joshi SS, Kucuk O, Carthon BC, Bilen MA, Abiodun-Ojo OA, Akintayo AA, Dhere VR, Schuster DM. 18F-fluciclovine-PET/CT imaging versus conventional imaging alone to guide postprostatectomy salvage radiotherapy for prostate cancer (EMPIRE-1): a single centre, open-label, phase 2/3 randomised controlled trial. Lancet 2021; 397:1895-1904. [PMID: 33971152 PMCID: PMC8279109 DOI: 10.1016/s0140-6736(21)00581-x] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/04/2021] [Accepted: 03/02/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Molecular imaging is increasingly used to guide treatment decisions and planning in prostate cancer. We aimed to evaluate the role of 18F-fluciclovine-PET/CT in improving cancer control compared with conventional imaging (bone scan and either CT or MRI) alone for salvage postprostatectomy radiotherapy. METHODS In EMPIRE-1, a single-centre, open-label, phase 2/3 randomised controlled trial, patients with prostate cancer with detectable PSA after prostatectomy and negative conventional imaging (no extrapelvic or bone findings) were randomly assigned in a 1:1 ratio to radiotherapy directed by conventional imaging alone or to conventional imaging plus 18F-fluciclovine-PET/CT. Computer-generated randomisation was stratified by PSA concentration, adverse pathology indicators, and androgen deprivation therapy intent. In the 18F-fluciclovine-PET/CT group, radiotherapy decisions were rigidly determined by PET findings, which were also used for target delineation. The primary endpoint was 3 year event-free survival, with events defined as biochemical or clinical recurrence or progression, or initiation of systemic therapy, using univariate and multivariable analyses in patients who received radiotherapy. This trial is registered with ClinicalTrials.gov, NCT01666808 and is closed to new participants. FINDINGS From Sept 18, 2012, to March 4, 2019, 165 patients were randomly assigned, with median follow-up of 3·52 years (95% CI 2·98-3·95). PET findings resulted in four patients in the 18F-fluciclovine-PET/CT group having radiotherapy aborted; these patients were excluded from survival analyses. Median survival was not reached (95% CI 35·2-not reached; 33% of 81 patients had events) in the conventional imaging group compared with not reached (95% CI not reached-not reached; 20% of 76 patients) in the 18F-fluciclovine-PET/CT group, and 3 year event-free survival was 63·0% (95% CI 49·2-74·0) in the conventional imaging group versus 75·5% (95% CI 62·5-84·6) for 18F-fluciclovine-PET/CT (difference 12·5; 95% CI 4·3-20·8; p=0·0028). In adjusted analyses, study group (hazard ratio 2·04 [95% CI 1·06-3·93], p=0·0327) was significantly associated with event-free survival. Toxicity was similar in both study groups, with the most common adverse events being late urinary frequency or urgency (37 [46%] of 81 patients in the conventional imaging group and 31 [41%] of 76 in the PET group), and acute diarrhoea (11 [14%] in the conventional imaging group and 16 [21%] in the PET group). INTERPRETATION Inclusion of 18F-fluciclovine-PET into postprostatectomy radiotherapy decision making and planning significantly improved survival free from biochemical recurrence or persistence. Integration of novel PET radiotracers into radiotherapy decisions and planning for prostate cancer patients warrants further study. FUNDING National Institutes of Health/National Cancer Institute, Blue Earth Diagnostics, and Winship Cancer Institute of Emory University.
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Affiliation(s)
- Ashesh B Jani
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA.
| | - Eduard Schreibmann
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Subir Goyal
- Biostatistics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Raghuveer Halkar
- Department of Radiology and Imaging Sciences, Emory University, Atlanta GA, USA
| | - Bruce Hershatter
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Peter J Rossi
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Joseph W Shelton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Pretesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Karen M Xu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Mark Goodman
- Department of Radiology and Imaging Sciences, Emory University, Atlanta GA, USA
| | - Viraj A Master
- Department of Urology, Emory University, Atlanta GA, USA
| | | | - Omer Kucuk
- Department of Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Bradley C Carthon
- Department of Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Mehmet A Bilen
- Department of Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | | | - Akinyemi A Akintayo
- Department of Radiology and Imaging Sciences, Emory University, Atlanta GA, USA
| | - Vishal R Dhere
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - David M Schuster
- Department of Radiology and Imaging Sciences, Emory University, Atlanta GA, USA
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10
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Edwards R, Greenwood HE, McRobbie G, Khan I, Witney TH. Robust and Facile Automated Radiosynthesis of [ 18F]FSPG on the GE FASTlab. Mol Imaging Biol 2021; 23:854-864. [PMID: 34013395 PMCID: PMC8578107 DOI: 10.1007/s11307-021-01609-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/19/2021] [Accepted: 04/18/2021] [Indexed: 01/18/2023]
Abstract
Purpose (S)-4-(3-18F-Fluoropropyl)-ʟ-Glutamic Acid ([18F]FSPG) is a radiolabeled non-natural amino acid that is used for positron emission tomography (PET) imaging of the glutamate/cystine antiporter, system xC-, whose expression is upregulated in many cancer types. To increase the clinical adoption of this radiotracer, reliable and facile automated procedures for [18F]FSPG production are required. Here, we report a cassette-based method to produce [18F]FSPG at high radioactivity concentrations from low amounts of starting activity. Procedures An automated synthesis and purification of [18F]FSPG was developed using the GE FASTlab. Optimization of the reaction conditions and automated manipulations were performed by measuring the isolated radiochemical yield of [18F]FSPG and by assessing radiochemical purity using radio-HPLC. Purification of [18F]FSPG was conducted by trapping and washing of the radiotracer on Oasis MCX SPE cartridges, followed by a reverse elution of [18F]FSPG in phosphate-buffered saline. Subsequently, the [18F]FSPG obtained from the optimized process was used to image an animal model of non-small cell lung cancer. Results The optimized protocol produced [18F]FSPG in 38.4 ± 2.6 % radiochemical yield and >96 % radiochemical purity with a molar activity of 11.1 ± 7.7 GBq/μmol. Small alterations, including the implementation of a reverse elution and an altered Hypercarb cartridge, led to significant improvements in radiotracer concentration from <10 MBq/ml to >100 MBq/ml. The improved radiotracer concentration allowed for the imaging of up to 20 mice, starting with just 1.5 GBq of [18F]Fluoride. Conclusions We have developed a robust and facile method for [18F]FSPG radiosynthesis in high radiotracer concentration, radiochemical yield, and radiochemical purity. This cassette-based method enabled the production of [18F]FSPG at radioactive concentrations sufficient to facilitate large-scale preclinical experiments with a single prep of starting activity. The use of a cassette-based radiosynthesis on an automated synthesis module routinely used for clinical production makes the method amenable to rapid and widespread clinical translation. Supplementary Information The online version contains supplementary material available at 10.1007/s11307-021-01609-w.
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Affiliation(s)
- Richard Edwards
- School of Biomedical Engineering & Imaging Sciences, King's College London, St. Thomas' Hospital, London, SE1 7EH, UK
| | - Hannah E Greenwood
- School of Biomedical Engineering & Imaging Sciences, King's College London, St. Thomas' Hospital, London, SE1 7EH, UK
| | - Graeme McRobbie
- Pharmaceutical Diagnostics, Life Sciences, GE Healthcare, Pollards Wood, Nightingales Lane, Chalfont St. Giles, Buckinghamshire, HP8 4SP, UK
| | - Imtiaz Khan
- Pharmaceutical Diagnostics, Life Sciences, GE Healthcare, Pollards Wood, Nightingales Lane, Chalfont St. Giles, Buckinghamshire, HP8 4SP, UK
| | - Timothy H Witney
- School of Biomedical Engineering & Imaging Sciences, King's College London, St. Thomas' Hospital, London, SE1 7EH, UK.
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11
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Dreyfuss AD, Ahn GS, Barsky AR, Gillman JA, Vapiwala N, Pantel AR. 18F-Fluciclovine PET/CT in Therapeutic Decision Making for Prostate Cancer: A Large Single-Center Practice-Based Analysis. Clin Nucl Med 2021; 46:187-194. [PMID: 33315672 DOI: 10.1097/rlu.0000000000003444] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
METHODS We carried out a retrospective cohort study of patients with BR after primary treatment of PC who received imaging with 18F-fluciclovine PET/CT at our institution between January 2010 and January 2019. PET/CT results were compared with biopsy, conventional imaging results, and/or response to PC therapy. 18F-Fluciclovine PET/CT performance statistics and effects on treatment planning were calculated. RESULTS A total of 328 patients with a median age of 71 years (range, 47-90 years) and median serum prostate-specific antigen level of 1.6 ng/mL (0.02-186.7 ng/mL) were included. Three hundred thirty-six 18F-fluciclovine PET/CT scans were analyzed and classified as positive (65%), negative (25%), or equivocal (10%) based on radiology reports. Sensitivity was 93% (95% confidence interval, 86%-96%) and specificity was 63% (95% confidence interval, 45%-77%). Of patients with known management recommendations post-PET/CT, scan results changed or influenced pre-PET/CT management plans in 73%, and 58% of recommendations involved treatment modality decisions. Overall, 82% of patients' actual management was concordant with post-PET/CT recommendations. Of evaluable patients, 116 (35%) had some form of post-PET radiotherapy included in their care plans, with 95% receiving radiotherapy at a PET-avid target. CONCLUSIONS In the largest single-institutional cohort to date, 18F-fluciclovine PET/CT showed value in the workup of PC in the setting of BR, with noteworthy influence over clinical management decisions. Further studies are needed to evaluate whether PET/CT-based changes in management are associated with improved outcomes.
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Affiliation(s)
- Alexandra D Dreyfuss
- From the Department of Radiation Oncology, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Grace S Ahn
- University of California San Diego School of Medicine, University of California San Diego, La Jolla, CA
| | - Andrew R Barsky
- From the Department of Radiation Oncology, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Jennifer A Gillman
- Division of Nuclear Medicine and Clinical Molecular Imaging, Department of Radiology, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Neha Vapiwala
- From the Department of Radiation Oncology, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Austin R Pantel
- Division of Nuclear Medicine and Clinical Molecular Imaging, Department of Radiology, Hospital of University of Pennsylvania, Philadelphia, PA
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12
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Wahl RL, Hicks RJ. PET Diagnosis and Response Monitoring in Oncology. Mol Imaging 2021. [DOI: 10.1016/b978-0-12-816386-3.00048-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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13
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Rowe SP, Johnson GB, Pomper MG, Gorin MA, Behr SC. Recent updates and developments in PET imaging of prostate cancer. Abdom Radiol (NY) 2020; 45:4063-4072. [PMID: 32417934 DOI: 10.1007/s00261-020-02570-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A number of positron emission tomography (PET) radiotracers have been developed to improve the sensitivity and specificity of imaging for prostate cancer. These radiotracers include the bone-seeking agent Na18F as well as more tumor-specific compounds such as 11C-choline and 18F-fluciclovine. In this review, we will discuss the advantages and disadvantages of these PET radiotracers for the imaging of men with prostate cancer across a range of clinical contexts. We will also touch upon radiotracers in late clinical development that have not gained regulatory approval, including those targeted against prostate-specific membrane antigen (PSMA) and gastrin-releasing peptide receptor (GRPR).
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Affiliation(s)
- Steven P Rowe
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Geoffrey B Johnson
- Division of Nuclear Medicine, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Martin G Pomper
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael A Gorin
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Spencer C Behr
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
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14
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Solanki AA, Savir-Baruch B, Liauw SL, Michalski J, Tward JD, Vapiwala N, Teoh EJ, Adler LP, Andriole GL, Belkoff LH, Burzon D, Chau A, Dato P, Duan F, Farwell M, Fogelson S, Gardiner P, Hanna L, Hoffman JM, Intenzo C, Josephson D, Kaminetsky J, Kipper M, Kostakoglu L, Krynyckyi B, Linder KE, Mahmood U, Marques H, Mankoff D, McConathy J, Melnick J, Miller MP, Oh W, Philips S, Rose J, Savir-Baruch B, Schuster DM, Siegel BA, Stevens DJ, Tewari A, Twardowski P, Ward P, Wasserman M, Weick S, (Michael) Yu JQ. 18F-Fluciclovine Positron Emission Tomography in Men With Biochemical Recurrence of Prostate Cancer After Radical Prostatectomy and Planning to Undergo Salvage Radiation Therapy: Results from LOCATE. Pract Radiat Oncol 2020; 10:354-362. [DOI: 10.1016/j.prro.2020.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
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15
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18F-fluciclovine PET CT detection of biochemical recurrent prostate cancer at specific PSA thresholds after definitive treatment. Urol Oncol 2020; 38:636.e1-636.e6. [DOI: 10.1016/j.urolonc.2020.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 02/29/2020] [Accepted: 03/21/2020] [Indexed: 11/17/2022]
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16
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Quesada-Olarte JM, Allaf ME, Alvarez-Maestro M, Martínez-Piñeiro L. Molecular imaging of prostate cancer: Review of imaging agents, modalities, and current status. Actas Urol Esp 2020; 44:386-399. [PMID: 32709428 DOI: 10.1016/j.acuro.2019.12.003] [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: 12/11/2019] [Accepted: 12/17/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The clinical course of Prostate cancer (PCa) are markedly diverse, ranging from indolent to highly aggressive disseminated disease. Molecular imaging techniques are playing an increasing role in early PCa detection, staging and disease recurrence. There are some molecular imaging modalities, radiotracers agents and its performance are important in current clinical practice PCa. OBJECTIVE This review summarizes the latest information regarding molecular imaging of PCa and is designed to assist urologists with ordering and interpreting these modalities and different radiotracers for different patients. EVIDENCE ACQUISITION A PubMed-based literature search was conducted up to September 2019. We selected the most recent and relevant original articles, metanalysis and reviews that have provided relevant information to guide molecular imaging modalities and radiotracers use. EVIDENCE SYNTHESIS In this review, we discuss 3 main molecular imaging modalities and 7 radiotracer technologies available. CONCLUSIONS The use molecular imaging modalities and radiotracers has a unique role in biochemical recurrence and diagnosis of ganglionar and bone progression of PCa. In the present time, no one of these molecular imaging modalities can be recommended over the classical work-up of abdominopelvic CT scan and bone scan, and large-scale and multi-institutional studies are required to validate the efficacy and cost utility of these new technologies.
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Affiliation(s)
| | - M E Allaf
- Departamento de Urología, Johns Hopkins University Hospital, Baltimore, Estados Unidos
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17
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Scarsbrook AF, Bottomley D, Teoh EJ, Bradley KM, Payne H, Afaq A, Bomanji J, van As N, Chua S, Hoskin P, Chambers A, Cook GJ, Warbey VS, Han S, Leung HY, Chau A, Miller MP, Gleeson FV. Effect of 18F-Fluciclovine Positron Emission Tomography on the Management of Patients With Recurrence of Prostate Cancer: Results From the FALCON Trial. Int J Radiat Oncol Biol Phys 2020; 107:316-324. [PMID: 32068113 DOI: 10.1016/j.ijrobp.2020.01.050] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/17/2019] [Accepted: 01/31/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Andrew F Scarsbrook
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; University of Leeds, Leeds, United Kingdom.
| | | | | | - Kevin M Bradley
- PETIC, Wales Research and Diagnostic PET Imaging Centre, Cardiff, United Kingdom
| | - Heather Payne
- University College London Hospitals, NHS Foundation Trust, London, United Kingdom
| | - Asim Afaq
- University College London Hospitals, NHS Foundation Trust, London, United Kingdom
| | - Jamshed Bomanji
- University College London Hospitals, NHS Foundation Trust, London, United Kingdom
| | - Nicholas van As
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Sue Chua
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Peter Hoskin
- Mount Vernon Cancer Centre, London, United Kingdom
| | | | - Gary J Cook
- King's College London and Guy's & St Thomas' PET Centre, St Thomas' Hospital, London, United Kingdom
| | - Victoria S Warbey
- King's College London and Guy's & St Thomas' PET Centre, St Thomas' Hospital, London, United Kingdom
| | - Sai Han
- West of Scotland PET Centre, Gartnavel General Hospital, Glasgow, United Kingdom
| | - Hing Y Leung
- Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom; CRUK Beatson Institute, Glasgow, United Kingdom
| | - Albert Chau
- Blue Earth Diagnostics, Oxford, United Kingdom
| | | | - Fergus V Gleeson
- Departments of Radiology and Nuclear Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Menon H, Guo C, Verma V, Simone CB. The Role of Positron Emission Tomography Imaging in Radiotherapy Target Delineation. PET Clin 2020; 15:45-53. [PMID: 31735301 DOI: 10.1016/j.cpet.2019.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Positron emission tomography (PET) is an advanced functional imaging modality in oncology care for the diagnosis, staging, prognostication, and surveillance of numerous malignancies. PET can also offer considerable advantages for target volume delineation as part of radiation treatment planning. In this review, data and clinical practice from 6 general oncology disease sites are assessed to descriptively evaluate the role of PET in target volume delineation. Also highlighted are several specific and practical utilities for PET imaging in radiation treatment planning. Publication of several ongoing prospective trials in the future may further expand the utility of PET for target delineation and patient care.
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Affiliation(s)
- Hari Menon
- University of Arizona College of Medicine, 475 N 5th St, Phoenix, AZ 85004, USA
| | - Chunxiao Guo
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, USA
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, 225 East 126th Street, New York, NY 10035, USA.
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Esther J, Dorff TB, Maughan BL. Recent developments in the treatment of non-metastatic castration resistant prostate cancer. Cancer Treat Res Commun 2020; 24:100181. [PMID: 32673844 DOI: 10.1016/j.ctarc.2020.100181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 11/26/2022]
Abstract
Non-metastatic castration resistant prostate cancer (nmCRPC) is defined as a disease state withlack of radiographic evidence of metastatic disease, a confirmed rising PSA level on continuous ADT and maintaining a castrate level of testosterone following definitive therapy. Prior to the publication of PROSPER, SPARTAN and ARAMIS, no trials have demonstrated a clinical benefit for these patients. Recently enzalutamide, apalutamide, and darolutamide respectively, were tested in this disease setting with metastasis free survival (MFS) as the primary endpoint for each trial. In this review article, we define key terms related to the discussion of nmCRPC, examine the clinical trial design, and safety profile for each of these three key clinical trials and present updated overall survival (OS) results from these studies. Also we specifically discuss the key clinical trial results including the primary endpoint of MFS for each trial as well as quality of life effects of these three androgen receptor antagonists. Finally, this article examines the potential impact of molecular imaging testing on the applicability of these clinical trial results.
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Affiliation(s)
- John Esther
- University of Utah Hospital, UT 84103, United States.
| | - Tanya B Dorff
- University of Utah Hospital, UT 84103, United States
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Lovrec P, Schuster DM, Wagner RH, Gabriel M, Savir-Baruch B. Characterizing and Mitigating Bladder Radioactivity on 18F-Fluciclovine PET/CT. J Nucl Med Technol 2019; 48:24-29. [DOI: 10.2967/jnmt.119.230581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/08/2019] [Indexed: 11/16/2022] Open
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A phase 0 study of the pharmacokinetics, biodistribution, and dosimetry of 188Re-liposome in patients with metastatic tumors. EJNMMI Res 2019; 9:46. [PMID: 31119414 PMCID: PMC6531516 DOI: 10.1186/s13550-019-0509-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 04/17/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Liposomes are drug nano-carriers that are capable of targeting therapeutics to tumor sites because of enhanced permeability retention (EPR). In several preclinical studies with various tumor-bearing mice models, 188Re-liposome that has been developed by the Institute of Nuclear Energy Research (INER) demonstrates favorable in vivo tumor targeting, biodistribution, pharmacokinetics, and dosimetry. It inhibits the growth of tumors, increased survival, demonstrates good synergistic combination, and was safe to use. This study conducts a phase 0 low-radioactivity clinical trial of nano-targeted radiotherapeutics 188Re-liposome to evaluate the effectiveness with which it targets tumors and the pharmacokinetics, biodistribution, dosimetry, and its safety in use. Twelve patients with metastatic cancers are studied in this trial. Serial whole-body scans and SPECT/CT are taken at 1, 4, 8, 24, 48, and 72 h after intravenous injection of 111 MBq of 188Re-liposome. The effectiveness with which tumors are targeted, the pharmacokinetics, biodistribution, dosimetry, and safety are evaluated using the VelocityAI and OLINDA/EXM software. Blood samples are collected at different time points for a pharmacokinetics study and a safety evaluation that involves monitoring changes in liver, renal, and hematological functions. RESULTS The T½z for 188Re-liposome in blood and plasma are 36.73 ± 14.00 h and 52.02 ± 45.21 h, respectively. The doses of radiation that are absorbed to vital organs such as the liver, spleen, lung, kidney, and bone marrow are 0.92 ± 0.35, 1.38 ± 1.81, 0.58 ± 0.28, 0.32 ± 0.09, and 0.06 ± 0.01 mGy/MBq, respectively, which is far less than the reference maximum tolerance dose after injection of 188Re-liposome. 188Re-liposome is absorbed by metastatic tumor lesions and the normal reticuloendothelial (RES) system. Certain patients exhibit a therapeutic response. CONCLUSION This phase 0 exploratory IND study shows that nanocarrier 188Re-liposome achieves favorable tumor accumulation and tumor to normal organ uptake ratios for a subset of cancer patients. The clinical pharmacokinetic, biodistribution, and dosimetry results justify a further dose-escalating phase 1 clinical trial. TRIAL REGISTRATION Taiwan FDA MA1101G0 (Jan 31, 2012).
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Xu KM, Chen RC, Schuster DM, Jani AB. Role of novel imaging in the management of prostate cancer. Urol Oncol 2019; 37:611-618. [PMID: 31072791 DOI: 10.1016/j.urolonc.2019.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 03/13/2019] [Accepted: 04/09/2019] [Indexed: 12/12/2022]
Abstract
This review summarizes novel imaging in the management of prostate cancer including multiparametric MRI, PET-CT scans with different radiotracers including 11C-acetate, 11C-choline, 18F-choline, 18F sodium fluoride, prostate-specific membrane antigen, and anti-1-amino-3-[18F] fluorocyclobutane-1-carboxylic acid (fluciclovine).
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Affiliation(s)
- Karen M Xu
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Emory University, Atlanta, GA
| | - Ronald C Chen
- Department of Radiation Oncology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - David M Schuster
- Department of Radiology and Imaging Sciences, Division of Nuclear Medicine and Molecular Imaging, Emory University Hospital, Atlanta, GA
| | - Ashesh B Jani
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Emory University, Atlanta, GA.
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Savir-Baruch B, Tade F, Henry E, Goldberg A, Petra L, Gabriel M, Wagner RH. Emerging Role of Fluciclovine and Other Next Generation PET Imaging Agents in Prostate Cancer Management. CURRENT RADIOLOGY REPORTS 2019. [DOI: 10.1007/s40134-019-0328-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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McInnes MD, Lim CS, van der Pol CB, Salameh JP, McGrath TA, Frank RA. Reporting Guidelines for Imaging Research. Semin Nucl Med 2019; 49:121-135. [DOI: 10.1053/j.semnuclmed.2018.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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25
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Andriole GL, Kostakoglu L, Chau A, Duan F, Mahmood U, Mankoff DA, Schuster DM, Siegel BA. The Impact of Positron Emission Tomography with 18F-Fluciclovine on the Treatment of Biochemical Recurrence of Prostate Cancer: Results from the LOCATE Trial. J Urol 2019; 201:322-331. [PMID: 30179618 DOI: 10.1016/j.juro.2018.08.050] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The prospective, multicenter LOCATE (F Fluciclovine [FACBC] PET/CT in Patients with Rising PSA after Initial Prostate Cancer Treatment) trial assessed the impact of positron emission tomography/computerized tomography with F-fluciclovine on treatment plans in patients with biochemical recurrence of prostate cancer after primary therapy with curative intent. MATERIALS AND METHODS Men who had undergone curative intent treatment of histologically confirmed prostate cancer but who were suspected to have recurrence based on rising prostate specific antigen levels were enrolled prospectively. Each man had negative or equivocal findings on standard of care imaging. F-fluciclovine positron emission tomography/computerized tomography was performed according to standardized protocols. Treating physicians completed a questionnaire regarding the patient treatment plan before and after scanning, recording changes to the treatment modality (eg salvage radiotherapy to systemic androgen deprivation therapy) as major and changes in a modality (eg modified radiotherapy fields) as other. RESULTS Between June 2016 and May 2017, 213 evaluable patients with a median age of 67 years and median prostate specific antigen 1.00 ng/ml were enrolled in study. F-fluciclovine avid lesions were detected in 122 of the 213 patients (57%). Overall 126 of the 213 patients (59%) had a change in management after the scan, which were major in 98 of 126 (78%) and in 88 (70%) were informed by positive positron emission tomography/computerized tomography findings. The most frequent major changes were from salvage or noncurative systemic therapy to watchful waiting (32 of 126 cases or 25%), from noncurative systemic therapy to salvage therapy (30 of 126 or 24%) and from salvage therapy to noncurative systemic therapy (11 of 126 or 9%). CONCLUSIONS F-fluciclovine positron emission tomography/computerized tomography detected 1 or more recurrence sites in the majority of men with biochemical recurrence, frequently resulting in major changes to management plans. Future studies will be planned to determine whether a management change leads to improved outcomes.
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Affiliation(s)
- Gerald L Andriole
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.,Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Lale Kostakoglu
- Division of Nuclear Medicine and Molecular Imaging, Icahn School of Medicine, Mount Sinai, New York, New York
| | - Albert Chau
- Blue Earth Diagnostics, Oxford, United Kingdom
| | - Fenghai Duan
- Department of Biostatistics and Center for Statistical Sciences, Brown University School of Public Health, Providence, Rhode Island
| | - Umar Mahmood
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - David A Mankoff
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David M Schuster
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Barry A Siegel
- Division of Nuclear Medicine, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri.,Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
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Glaser ZA, Rais-Bahrami S. Fluciclovine positron emission tomography in the setting of biochemical recurrence following local therapy of prostate cancer. Transl Androl Urol 2018; 7:824-830. [PMID: 30456185 PMCID: PMC6212627 DOI: 10.21037/tau.2018.07.17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Approximately one in five men will demonstrate biochemical recurrence (BCR) following local therapy for prostate cancer (PCa). Advanced imaging modalities including positron emission tomography (PET) imaging of various radiotracers have become more commonplace to visualize foci of disease recurrence. We performed a systematic review of the literature to describe current evidence in support of 18F-fluciclovine (Axumin) PET imaging in this clinical setting. An English literature search was conducted on PubMed/Medline for original investigations on 18F-fluciclovine PET for PCa. Boolean criteria included the terms: prostate, fluciclovine, FACBC and Axumin. Published articles meeting these criteria and their respective bibliographies and diagnostic modalities were included after review, when appropriate. Our literature review identified 93 articles. Among these, 18 met our inclusion criteria. Evidence suggests 18F-fluciclovine PET imaging is safe, well-tolerated and offers acceptable sensitivity and specificity for the detection of localized intraglandular and extraprostatic PCa foci in the setting of persistence or recurrence after primary treatment. Compared to other available PET radiotracers available, evidence suggests that 18F-fluciclovine may outperform ProstaScint and 11C-choline in this clinical setting. Furthermore, 18F-fluciclovine PET may aid guiding decision-making in regards to salvage therapy planning. Further investigation is warranted to validate these early findings and to further compare this agent to other available radiotracers in this setting.
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Affiliation(s)
- Zachary A Glaser
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Soroush Rais-Bahrami
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
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Casas F, Valduvieco I, Oses G, Izquierdo L, Archila I, Costa M, Cortes KS, Barreto T, Ferrer F. Postoperative adjuvant and very early salvage radiotherapy after prostatectomy in high-risk prostate cancer patients can improve specific and overall survival. Clin Transl Oncol 2018; 21:355-362. [PMID: 30128953 DOI: 10.1007/s12094-018-1931-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/30/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Adjuvant radiotherapy (ART) for biochemical relapse (BR) after radical prostatectomy (RP) showed increased disease-free survival (DFS) in three previous randomized trials. Retrospective phase II trials evaluated if early salvage RT (ESRT) is equivalent to ART. Our study aims to compare ART and ESRT to salvage RT. MATERIALS AND METHODS We compared RP plus ART and ESRT versus SRT. Indication for RT was made by PSA determination after RP: ART when PSA ≤ 0.2 ng/ml, ESRT when PSA ≤ 0.3 after PSA rise from 0.0 to SRT PSA ≥ 0.3. The cause of death of each patients was analyzed, DFS, cause-specific survival (CSS) overall survival (OS) and metastasis-free survival (MFS) in relation to RT intention. RESULTS Between 1993 and 2008, 204 patients with a median age of 65 years (44-75) were treated. The median follow-up was 160 months (28.1-273.3). At diagnosis, 89.7% had localized clinical stages and 90.2% had Gleason (G) ≤ 7. The median PSA was 10 (range 4-101). The postoperative G was ≥ 7 in 66.2%; 56.4% had ≥ 2 positive margins; 29.4% received ART, 20% ESRT and 59.3% SRT. The DFS for ART, ESRT and SRT was 74, 56 and 39% with significant differences between the three groups (p < 0.001). ART + ESRT were combined versus SRT; for the DFS, the significant differences (p < 0.001) remained 67% versus 39%. Positive margins, pT3 and pre-RT PSA were significant factors on multivariate analysis. The CSS in the ART + ESRT group was 92 vs. 78% in the SRT group (p < 0.05). OS was 69% in ART + ESRT vs. 57% in SRT (p < 0.05). MFS was 82.7% in ART + ESRT vs. 67.4% in SRT. CONCLUSIONS In this study the ART + ESRT presented benefits versus SRT in DFS, CSS, OS and MFS.
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Affiliation(s)
- F Casas
- Radiation Oncology Department, Hospital Clínic, Barcelona, Spain.
| | - I Valduvieco
- Radiation Oncology Department, Hospital Clínic, Barcelona, Spain
| | - G Oses
- Radiation Oncology Department, Hospital Clínic, Barcelona, Spain
| | - L Izquierdo
- Urology Department, Hospital Clínic, Barcelona, Spain
| | - I Archila
- Pathology Department, Hospital Clínic, Barcelona, Spain
| | - M Costa
- Urology Department, Hospital Clínic, Barcelona, Spain
| | - K S Cortes
- Radiation Oncology Department, Hospital Clínic, Barcelona, Spain
| | - T Barreto
- Radiation Oncology Department, Hospital Clínic, Barcelona, Spain
| | - F Ferrer
- Radiation Oncology Department, Institut Català d'Oncologia, IDIBELL, Universitat de Barcelona, Barcelona, Spain
- Departament de Ciències Clíniques, Universitat de Barcelona, Barcelona, Spain
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Sharma V, Nehra A, Colicchia M, Westerman ME, Kawashima A, Froemming AT, Kwon ED, Mynderse LA, Karnes RJ. Multiparametric Magnetic Resonance Imaging Is an Independent Predictor of Salvage Radiotherapy Outcomes After Radical Prostatectomy. Eur Urol 2018; 73:879-887. [DOI: 10.1016/j.eururo.2017.11.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 11/14/2017] [Indexed: 01/09/2023]
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29
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Kishan AU, Tendulkar RD, Tran PT, Parker CC, Nguyen PL, Stephenson AJ, Carrie C. Optimizing the Timing of Salvage Postprostatectomy Radiotherapy and the Use of Concurrent Hormonal Therapy for Prostate Cancer. Eur Urol Oncol 2018; 1:3-18. [PMID: 31100226 DOI: 10.1016/j.euo.2018.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 02/12/2018] [Indexed: 12/22/2022]
Abstract
CONTEXT Currently, salvage radiotherapy (SRT) is the only known curative intervention for men with recurrent disease following prostatectomy. Critical issues in the optimal selection and management of men being considered for SRT include the threshold prostate-specific antigen (PSA) value at which to initiate treatment (ie, pre-SRT PSA) and the role of concurrent hormonal therapy (HT). OBJECTIVE To review the published evidence pertaining to the optimal timing for SRT and the role of concurrent HT. EVIDENCE ACQUISITION MEDLINE (via PubMed), EMBASE, the Cochrane Central Register of Controlled Trials, and guideline statements from professional organizations were queried from January 1, 2000 through January 10, 2018. EVIDENCE SYNTHESIS Thirty-three independent reports, including two randomized trials evaluating HT with SRT, were identified. Retrospective data suggest that SRT initiation at lower pre-SRT PSA levels is associated with better clinical outcomes. Prospective data suggest an overall survival benefit with concurrent HT that manifests during long-term follow-up, with the caveat that hypothesis-generating subgroup analyses suggest that this benefit may be limited to patients with higher pre-SRT PSA levels. Patients with adverse risk factors, such as Gleason grade group 4-5 disease, are likely to benefit the most from earlier SRT initiation and/or the use of HT. CONCLUSIONS Given the limitations of the available data, it is imperative that physicians participate in shared decision-making, with the recommendation tailored for each man's desire to maximize oncologic benefit (with a risk of overtreatment) versus potential quality-of-life optimization (with a risk of undertreatment). Within that framework, a significant body of retrospective data supports initiation of SRT at low pre-SRT PSA values, without an arbitrary absolute threshold. Prospective data suggest a benefit of HT, but this benefit may be greatest in patients with a pre-SRT PSA that is higher than the typical level in most patients receiving "early" SRT. Further research is necessary before absolute recommendations can be made. PATIENT SUMMARY Two ways to potentially improve outcomes following salvage radiotherapy for prostate cancer that recurs after prostatectomy are to start treatment at a lower prostate-specific antigen level and to use concurrent hormonal therapy. Our review suggests that the available evidence is imperfect, but highlights that both measures are likely to improve clinical outcomes in general, but perhaps not uniformly and/or consistently for all patients. Physician-patient shared decision-making and further research are critical.
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA; Department of Urology, University of California, Los Angeles, USA.
| | | | - Phuoc T Tran
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher C Parker
- The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, UK
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Hwang WL, Tendulkar RD, Niemierko A, Agrawal S, Stephans KL, Spratt DE, Hearn JW, Koontz BF, Lee WR, Michalski JM, Pisansky TM, Liauw SL, Abramowitz MC, Pollack A, Moghanaki D, Anscher MS, Den RB, Zietman AL, Stephenson AJ, Efstathiou JA. Comparison Between Adjuvant and Early-Salvage Postprostatectomy Radiotherapy for Prostate Cancer With Adverse Pathological Features. JAMA Oncol 2018; 4:e175230. [PMID: 29372236 PMCID: PMC5885162 DOI: 10.1001/jamaoncol.2017.5230] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 11/16/2017] [Indexed: 11/14/2022]
Abstract
Importance Prostate cancer with adverse pathological features (ie, pT3 and/or positive margins) after prostatectomy may be managed with adjuvant radiotherapy (ART) or surveillance followed by early-salvage radiotherapy (ESRT) for biochemical recurrence. The optimal timing of postoperative radiotherapy is unclear. Objective To compare the clinical outcomes of postoperative ART and ESRT administered to patients with prostate cancer with adverse pathological features. Design, Setting, and Participants This multi-institutional, propensity score-matched cohort study involved 1566 consecutive patients who underwent postprostatectomy ART or ESRT at 10 US academic medical centers between January 1, 1987, and December 31, 2013. Propensity score 1-to-1 matching was used to account for covariates potentially associated with treatment selection. Data were collected from January 1 to September 30, 2016. Data analysis was conducted from October 1, 2016, to October 21, 2017. Main Outcomes and Measures Freedom from postirradiation biochemical failure, freedom from distant metastases, and overall survival. All outcomes were measured from date of surgery to address lead-time bias. Results Of 1566 patients, 1195 with prostate-specific antigen levels of 0.1 to 0.5 ng/mL received ESRT and 371 patients with prostate-specific antigen levels lower than 0.1 ng/mL received ART. The median age (interquartile range) was 60 (55-65) years. After propensity score matching, the median (interquartile range) follow-up after surgery was similar between the ESRT and ART groups (73.3 [44.9-106.6] months vs 65.8 [40-107] months; P = .22). Adjuvant RT, compared with ESRT, was associated with higher freedom from biochemical failure (12-year actuarial rates: 69% [95% CI, 60%-76%] vs 43% [95% CI, 35%-51%]; effect size, 26%), freedom from distant metastases (95% [95% CI, 90%-97%] vs 85% [95% CI, 76%-90%]; effect size, 10%), and overall survival (91% [95% CI, 84%-95%] vs 79% [95% CI, 69%-86%]; effect size, 12%). Adjuvant RT, lower Gleason score and T stage, nodal irradiation, and postoperative androgen deprivation therapy were favorable prognostic features on multivariate analysis for biochemical failure. Sensitivity analysis demonstrated that the decreased risk of biochemical failure associated with ART remained significant unless more than 56% of patients in the ART group were cured by surgery alone. This threshold is greater than the estimated 12-year freedom from biochemical failure rate of 33% to 52% after radical prostatectomy alone, as determined by a contemporary dynamic nomogram. Conclusions and Relevance Adjuvant RT, compared with ESRT, was associated with reduced biochemical recurrence, distant metastases, and death for high-risk patients, pending prospective validation. These findings suggest that a greater proportion of patients with prostate cancer who have adverse pathological features may benefit from postprostatectomy ART rather than surveillance followed by ESRT.
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Affiliation(s)
- William L. Hwang
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rahul D. Tendulkar
- Departments of Radiation Oncology and Urology, Cleveland Clinic, Cleveland, Ohio
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shree Agrawal
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Kevin L. Stephans
- Departments of Radiation Oncology and Urology, Cleveland Clinic, Cleveland, Ohio
| | - Daniel E. Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Jason W. Hearn
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Bridget F. Koontz
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - W. Robert Lee
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jeff M. Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | | | - Stanley L. Liauw
- Department of Radiation Oncology, University of Chicago, Chicago, Illinois
| | | | - Alan Pollack
- Department of Radiation Oncology, University of Miami, Miami, Florida
| | - Drew Moghanaki
- Department of Radiation Oncology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Mitchell S. Anscher
- Department of Radiation Oncology, Virginia Commonwealth University Medical Center, Richmond
| | - Robert B. Den
- Department of Radiation Oncology, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Anthony L. Zietman
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J. Stephenson
- Departments of Radiation Oncology and Urology, Cleveland Clinic, Cleveland, Ohio
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Parent EE, Schuster DM. Update on 18F-Fluciclovine PET for Prostate Cancer Imaging. J Nucl Med 2018; 59:733-739. [PMID: 29523631 PMCID: PMC6910635 DOI: 10.2967/jnumed.117.204032] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/08/2018] [Indexed: 01/22/2023] Open
Abstract
PET is a functional imaging method that can exploit various aspects of tumor biology to enable greater detection of prostate cancer than can be provided by morphologic imaging alone. Anti-1-amino-3-18F-flurocyclobutane-1-carboxylic acid (18F-fluciclovine) is a nonnaturally occurring amino acid PET radiotracer that was recently approved by the U.S. Food and Drug Administration for detection of suspected recurrent prostate cancer. The tumor-imaging features of this radiotracer mirror the upregulation of transmembrane amino acid transport that occurs in prostate cancer because of increased amino acid metabolism for energy and protein synthesis. This continuing medical education article provides an overview on 18F-fluciclovine PET diagnostic capabilities for primary and metastatic disease, including reviews of published comparisons to conventional imaging and other molecular imaging agents. Additionally, the imaging procedure and image interpretation are detailed, including physiologic and pathologic uptake patterns and pitfalls.
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Affiliation(s)
- Ephraim E Parent
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - David M Schuster
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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Koontz BF. Stereotactic Body Radiation Therapy for Oligometastatic Prostate Cancer: The Hunt for the Silver Bullet. Int J Radiat Oncol Biol Phys 2017; 99:761-763. [PMID: 29063841 DOI: 10.1016/j.ijrobp.2017.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 05/15/2017] [Indexed: 11/29/2022]
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Oka S, Kanagawa M, Doi Y, Schuster DM, Goodman MM, Yoshimura H. PET Tracer 18F-Fluciclovine Can Detect Histologically Proven Bone Metastatic Lesions: A Preclinical Study in Rat Osteolytic and Osteoblastic Bone Metastasis Models. Am J Cancer Res 2017; 7:2048-2064. [PMID: 28656060 PMCID: PMC5485422 DOI: 10.7150/thno.19883] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 04/08/2017] [Indexed: 12/22/2022] Open
Abstract
18F-Fluciclovine (trans-1-amino-3-18F-fluorocyclobutanecarboxylic acid; anti-18F-FACBC) is a positron emission tomography (PET) tracer for diagnosing cancers (e.g., prostate and breast cancer). The most frequent metastatic organ of these cancers is bone. Fluciclovine-PET can visualize bony lesions in clinical practice; however, such lesions have not been described histologically. Methods: We investigated the potential of 14C-fluciclovine in aiding the visualization of osteolytic and osteoblastic bone metastases (with histological analyses), compared with 3H-2-deoxy-2-fluoro-D-glucose (3H-FDG), 3H-choline chloride (3H-choline), and 99mTc-hydroxymethylene diphosphonate (99mTc-HMDP) by using triple-tracer autoradiography in rat breast cancer osteolytic (on day 12 ± 1 postinjection of MRMT-1) and prostate cancer osteoblastic (on day 20 ± 3 postinjection of AT6.1) metastatic models. Results: The distribution patterns of 14C-fluciclovine, 3H-FDG, and 3H-choline, but not 99mTc-HMDP, were similar in both models, and the lesions where these tracers accumulated were, histologically, typical osteolytic and osteoblastic lesions. 99mTc-HMDP accumulated mostly in osteoblastic lesions. 14C-fluciclovine could visualize the osteolytic lesions as early as day 6 postinjection of MRMT-1. However, differential distributions in 14C-fluciclovine and 3H-FDG existed, based on histological differences: low 14C-fluciclovine and high 3H-FDG accumulation in osteolytic lesions with inflammation. In the osteoblastic metastatic model, visualization of osteoblastic lesions with 14C-fluciclovine was not clear, yet clearer than with 3H-FDG. Although half of the osteoblastic lesions with 14C-fluciclovine accumulation showed negligible 3H-choline accumulation in comparison, they were histologically similar to lesions with marked 14C-fluciclovine and 3H-choline accumulation. Conclusion: These results suggest that fluciclovine-PET can visualize true osteolytic and osteoblastic bone metastatic lesions.
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