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Elements recommended for determining likelihood of prostate cancer in given lesions (identified by arrows). (a) Comparison of fluciclovine uptake in nonosseous lesions to background; this is a para-aortic lymph node on fused axial image (left) and CT (right). (b) Lesion located at typical site of prostate cancer recurrence in the prostate gland in a patient given radiotherapy as initial definitive treatment (left image is axial fused and right image is corresponding CT). (c) Lesion located at typical site in lymph nodes (left image is axial fused, middle image is sagittal, and right image is coronal view). (d) Lesions located at atypical site for prostate cancer (lymph nodes). (e) Bone lesions as seen on an MIP image.
Source publication
The positron emission tomography (PET) tracer ¹⁸F-fluciclovine has seen increasing use to localize disease in men with biochemical recurrence of prostate cancer, i.e., elevated prostate-specific antigen (PSA) levels post-treatment. ¹⁸F-Fluciclovine PET/computed tomography (CT) imaging reports now play central roles in many physician-patient discuss...
Citations
... Since the approval of the F18-fluciclovine radiotracer by the United States FDA in May of 2016, the F18-fluciclovine PET/CT has become an increasingly popular tool used by providers to assess for prostate cancer recurrence [8,16]. It has been shown that the inclusion of F18-fluciclovine PET/CT into postprostatectomy radiotherapy decision-making and planning significantly improved survival free from biochemical recurrence or persistence [9,10]. ...
PET/CT scans are being used to assess patients who have experienced biochemical failure following surgery or radiation therapy for localized prostate cancer. We aimed to evaluate the language used in report impressions and to determine the level of confidence that radiologists have when reporting on lesions in various anatomic sites. Between 2015 and 2021, 295 F18-fluciclovine PET/CT scan reports were identified. Thirteen phrases commonly used by radiologists in the report impression section to describe a lesion of interest were identified and categorized into three confidence categories: definitive (positive and negative), likely (consistent with, most likely, favors, probable), and unsure (suspicious for, concerning for, non-specific, conspicuous, compatible with, borderline, unknown). The use of definitive language varied depending on the anatomic site, with the highest use in bone (87.1%) and the lowest use in the intact prostate (34.6%). In patients with a PSA < 0.5, there was the highest degree of definitive certainty (89.2%), whereas in patients with a PSA > 1, there was the least definitive certainty (66.2%). The language used in these reports has not been standardized, with definitive, likely, and unsure findings reported in 68.6%, 9.7%, and 21.7% of scans, respectively.
... As previously reported, 18 F-fluciclovine detection rates may differ between centers, possibly due to differences in acquisition protocols, scanner type, and/or readers' experience levels [21,22]. It may be that unfamiliarity with 18 Ffluciclovine reporting influenced results, but it has been shown that following limited specific training, naïve readers are able to read 18 F-fluciclovine images with good agreement [23]. ...
Background
A systematic literature review of the performance of ¹⁸ Fluorine-fluciclovine PET/CT for imaging of men with recurrent prostate cancer was performed.
Methods
Scientific literature databases (MEDLINE, ScienceDirect and Cochrane Libraries) were searched systematically during Oct 2020 using PRISMA criteria. No limit was put on the date of publication. Prospective studies reporting a patient-level ¹⁸ F-fluciclovine detection rate (DR) from ≥25 patients with recurrent prostate cancer were sought. Proceedings of relevant meetings held from 2018 through Oct 2020 were searched for abstracts meeting criteria.
Results
Searches identified 321 unique articles. In total, nine articles (six papers and three conference abstracts), comprising a total of 850 patients met inclusion criteria. Most studies ( n = 6) relied on ASTRO-Phoenix Criteria, EAU-ESTRO-SIOG, and/or ASTRO-AUA guidelines to identify patients with biochemical recurrence. Patients’ PSA levels ranged from 0.02–301.7 ng/mL (median level per study, 0.34–4.10 ng/mL [ n = 8]). Approximately 64% of patients had undergone prostatectomy, but three studies focused solely on post-prostatectomy patients. Adherence to imaging protocol guidelines was heterogeneous, with variance seen in administered activity, uptake and scan times. Overall patient-level DR varied between studies from 26% to 83%, with 78% of studies reporting a DR > 50%. DR was proportional to PSA, but even at PSA < 0.5 ng/mL DR of up to 53% were reported. Prostate/bed DR ( n = 7) ranged from 18% to 78% and extra-prostatic rates ( n = 6) from 8% to 72%. Pelvic node and bone lesion DR ranged from 8% to 47% and 0% to 26%, respectively ( n = 5). ¹⁸ F-Fluciclovine PET/CT was shown to impact patient management and outcomes. Two studies reported 59–63% of patients to have a management change post-scan. A further study showed significant increase in failure-free survival following ¹⁸ F-fluciclovine-guided compared with conventional imaging-guided radiotherapy planning.
Conclusions
¹⁸ F-Fluciclovine PET/CT shows good performance in patients with recurrent prostate cancer leading to measurable clinical benefits. Careful adherence to recommended imaging protocols may help optimize DR.
The imaging of prostate cancer at different disease states has undergone a series of quantum leaps in the past decade. Imaging in prostate cancer serves, in part, the purpose of staging and risk-stratifying patients to formulate the most effective treatment plan with the least adverse side effects. However, traditional imaging techniques could only serve this role with significant limitations. Computed tomography (CT), for instance, has a size criterion of 1 cm for lymph nodes as threshold of raising suspicion for malignancy, which would not detect sub-centimeter or microscopic nodal disease often encountered on pathologic specimens. Traditional Tc-99 m methylene diphosphonate (MDP) bone scan limited by inherent single photon emission scintigraphic spatial resolution in the 1 cm range would fall short of delineating early bone metastases. Magnetic resonance imaging (MRI), despite its exquisite soft tissue resolution, faces challenges in identifying malignant lymph nodes in sub-centimeter range. The new paradigm of molecular imaging allows for detection of disease at a molecular level, at a stage where often no macroscopic structural abnormality can be demonstrated. It holds the promise of answering questions not sufficiently answered by conventional imaging and better characterizes prostate cancer at it different stages.
Fluorine-18 fluorodeoxyglucose ([18F]FDG), the first radiopharmaceutical used in clinical
applications of positron emission tomography (PET), was a revolutionary development in nuclear medicine that combined biochemistry, medicinal chemistry and radiochemistry. In the 1970s, it was used in brain imaging to aid clinical diagnosis; soon, the detection of malignancies and cardiac diseases also became possible. In the decades that followed, [18F]FDG became widely available owing to the worldwide cyclotron network and automated synthesizers in clinics in many Member States. This paved the way for the development of additional 18F-labelled radiopharmaceuticals adapted for other biological pathways and molecular and cellular mechanisms applicable to human diseases. The production and quality control of 18F radiopharmaceuticals have been revolutionized
from the industrial point of view, with the introduction of national and international safety, legislative and legal requirements. In response to numerous requests from Member States, in 2020 the IAEA organized a number of consultancy meetings aimed at planning and preparing a publication on the production and quality control of 18F radiopharmaceuticals. The present publication is a result of those meetings and provides
information on practical production routes and on quality control and radiopharmaceutical aspects of 18F tracers. It is expected to be of interest to radiopharmacists and radiochemists, as well as graduate students in the field of 18F radiochemistry and radiopharmacy. The IAEA wishes to thank the participating experts for their valuable work and scientific contributions, especially P.H. Elsinga (Netherlands) for compiling and carrying out the technical editing of this publication and J. Vera Araujo (Bolivarian Republic of Venezuela) for her editorial support. The IAEA technical officer responsible for this publication was A.R. Jalilian of the Division of Physical and Chemical Sciences.
Prostate cancer (PCa) is one of the most commonly diagnosed malignancies and among the leading causes of cancer-related death worldwide. It is a highly heterogeneous disease, ranging from remarkably slow progression or inertia to highly aggressive and fatal disease. As therapeutic decision-making, clinical trial design and outcome highly depend on the appropriate stratification of patients to risk groups, it is imperative to differentiate between benign versus more aggressive states. The incorporation of clinically valuable prognostic and predictive biomarkers is also potentially amenable in this process, in the timely prevention of metastatic disease and in the decision for therapy selection. This review summarizes the progress that has so far been made in the identification of the genomic events that can be used for the classification, prediction and prognostication of PCa, and as major targets for clinical intervention. We include an extensive list of emerging biomarkers for which there is enough preclinical evidence to suggest that they may constitute crucial targets for achieving significant advances in the management of the disease. Finally, we highlight the main challenges that are associated with the identification of clinically significant PCa biomarkers and recommend possible ways to overcome such limitations.
