using pet/ct in prostate cancer · routinely since data on its utility in prostate cancer is...
TRANSCRIPT
Using PET/CT in Prostate Cancer
Legal Disclaimer
These materials were prepared in good faith by MITA as a service to
the profession and are believed to be reliable based on current
scientific literature. The materials are for educational purposes only and
do not replace either the need for individualized patient diagnosis and
treatment planning by qualified physicians based on existing good
practices or the need for implementation by qualified radiologists or
other qualified healthcare practitioners. Neither MITA nor its members
are responsible for any diagnostic or treatment outcomes. MITA, its
members, and contributors do not assume any responsibility for the
user’s compliance with applicable laws and regulations. MITA does not
endorse the proprietary products or processes of any one company.
Purpose and Audience
Provide urologists, surgeons, medical oncologists,
radiation oncologists and other prostate cancer
specialists with the following information to aid in the
diagnosis and management of prostate cancer patients
A summary of PET radiopharmaceuticals that are FDA-
approved to image prostate cancer
NCCN Practice Guidelines updates for using PET/CT in
prostate cancer
Recent Report from the National Oncologic
PET Registry (NOPR)
Impact on patient management
PET/CT in Prostate Cancer
PET/CT plays an important role in the evaluation of
prostate cancer on many levels
Detecting metastatic disease
Restaging
Biochemical relapse post-radical therapy
A biochemical relapse is one where, after completing treatment
(e.g., prostatectomy), PSA begins rising again but the cancer
cannot (yet) be detected by CT or MRI
Treatment monitoring
Use for primary staging generally limited to only high-risk
disease
Jadvar H. J Nucl Med 2013; 54(10):1685-1688
FDA-Approved PET Radiopharmaceuticals
for Prostate Cancer
Tracers that image metabolism
C-11 choline and F-18 fluciclovine
Used to localize disease recurrence in men who have
rising PSA and inconclusive conventional imaging
F-18 FDG
Used typically in patients with late-stage recurrent prostate
cancer and elevated PSA
Tracers that image bone
F-18 NaF (sodium fluoride)
Used to detect bone metastases
PET/CT in Prostate Cancer:
NCCN Guidelines
C-11 choline: Radioactive diagnostic agent for PET imaging of
patients with suspected prostate cancer recurrence and non-
informative bone scintigraphy, CT or MRI. In these patients, C-11
choline-PET/CT imaging may help identify potential sites of prostate
cancer recurrence for subsequent histologic confirmation
F-18 NaF: Newer technology using F-18 NaF for PET scanning can
be used as a diagnostic staging study; appears to have greater
sensitivity than Tc-99m bone scan for assessing bone metastasis
F-18 FDG: In certain clinical settings, the use of F-18 FDG may
provide useful information; F-18 FDG-PET/CT should not be used
routinely since data on its utility in prostate cancer is limited
F-18 fluciclovine: Indicated for PET imaging with suspected
prostate cancer recurrence based on elevated blood PSA levels
following prior treatment.
www.NCCN.org NCCN Guidelines Prostate Cancer, Version 1.2016 accessed 3/8/16
(NOTE: FDA approved fluciclovine May 2016; it is
not yet included in the NCCN guidelines.)
Cancer Guidelines: Overview for
Prostate Cancer Evaluation
The NCCN guidelines have specific recommendations when using PET/CT
imaging in prostate cancer: (1) primary disease, (2) biochemical recurrence and
(3) advanced disease. Below is a sample of information taken from these
guidelines. Please consult the NCCN website for their complete set of
guidelines. www.NCCN.org/prostate cancer guidelines accessed 3/8/16
PET/CT in Prostate Cancer:
Benefits of C-11 Choline Imaging
CMS may reimburse the use of C-11 choline-PET/CT in
biochemical failure (i.e., relapse of prostate cancer with
inconclusive bone scan, CT and/or MRI)
Contact your local MAC for your area’s coverage decision
Established tracer to identify progression to support
more appropriate treatment options
Shows soft tissue and osseous metastatic disease
Availability varies due to half-life of 20 minutes
Ceci F, et al. EJNMMI 2014; 41(12):2222-2231
CASE EXAMPLE: 74-year-old male with history of prostate
cancer and definitive therapy now presenting with
biochemical recurrence; CT and bone scan were negative.
PET/CT in Prostate Cancer:
Benefits of C-11 Choline Imaging
Results: C-11 choline-PET/CT revealed both soft tissue and
osseous multifocal metastases
R R R L L L
PET/CT in Prostate Cancer:
C-11 Choline Imaging Data
Recent publication: Ceci et al. 2014
150 patients with recurrent prostate cancer
Subjects having C-11 choline-PET/CT imaging resulted
in 46.7% overall treatment change
14% did not undergo radiation due to distant mets
18% had a major clinical change (note: paper did not
provide information on the reported change)
Ceci F, et al. EJNMMI 2014; 41(12):2222-2231
PET/CT in Prostate Cancer:
Benefits of F-18 NaF Imaging
SPECT PET/CT
Even-Sapir E, et al. J Nucl Med 2006; 47:287–297
F-18 NaF-PET/CT has higher sensitivity and specificity
than planar or SPECT bone scan using Tc-99m
Study compared planar and SPECT bone scan to F-18
NaF imaging in 44 patients with high-risk prostate cancer
23 (52%) had bone metastases
Test Sensitivity Specificity
Planar bone scan 70% 57%
Multi FOV SPECT 92% 82%
F-18 NaF-PET/CT 100% 100%
PET/CT in Prostate Cancer:
F-18 NaF Imaging Data
Even-Sapir E, et al. J Nucl Med 2006; 47:287–297
The National Oncologic PET Registry (NOPR) is a
mechanism for CMS Coverage
A registry for F-18 NaF-PET to identify bone metastasis
similar to that now in place for F-18 FDG-PET
Launched February 7, 2011
>30,000 scans with complete data submitted to date
PET/CT in Prostate Cancer:
F-18 NaF and NOPR
Hillner B, et al. J Nucl Med 2014; 55:574-581
F-18 NaF-PET changed intended management in 77%
of cases
Initial no treatment decision revised to treatment in 77%
Switch from initial staging [IS] to primary osseous
metastization [POM]
Therapy management changed in 44% to 52%
Consideration for coverage request for F-18 NaF still
under evaluation by CMS
Hillner B, et al. J Nucl Med 2014; 55:574-581
Impact of F-18 NaF on Prostate
Cancer Management
PET/CT in Prostate Cancer Recurrence:
Imaging with F-18 Fluciclovine
Emission image at 0.12h in healthy
adult volunteer following IV
administration of F-18 fluciclovine (McParland B, et al. EJNMMI 2013; 40(8):1256–1264)
PET (A) and PET/CT (B) image of fluciclovine in
man with biopsy-proven recurrence in the
prostate bed (Schuster et al. J Nucl Med 2007; 48:56–63)
The color scale ranges from radiotherapy dose of 0 to 77 Gy.
F-18 fluciclovine imaging can be used to plan
radiotherapy treatment
PET/CT in Prostate Cancer:
Image-Guided Radiotherapy Planning
Schreibmann E, et al. Int J Rad Onco 2016
A. Original radiotherapy
(Rx) treatment plan B. Fluciclovine imaging
results reveal iliac lymph
node involvement
C. Revised treatment plan
now includes involved LN
A B C
Impact of Prostate Cancer Imaging
on Disease Management
Change in management: a summary review of clinical
studies and the literature
C-11 choline-PET/CT1
7% in overall treatment change
18% in major changes
F-18 fluciclovine-PET/CT imaging in subjects undergoing
salvage radiotherapy treatment planning2
F-18 fluciclovine results changed planning volumes for 46/55
abnormalities: 28(51%) in the lymph nodes, 11(20%) in the
prostate bed, 10(18%) in the prostate and 6(11%) in the seminal
vesicles
1. Ceci F, et al. EJNMMI 2014; 41(12):2222-2231
2. Schreibmann E, et al. J Rad Onc Biol Phys 2016, doi:
10.1016/j.ijrobp.2016.04.023
Impact of Prostate Cancer Imaging
on Disease Management
Change in management: a summary review of clinical
studies and the literature (cont.)
F-18 NaF3,4
In specificity and sensitivity vs planar bone scan and multi-FOV
SPECT
In recognition of bone metastases for high-risk prostate cancer
patients (52%)
In intended management of NOPR patients (77%)
In changes in therapy management (44% to 52%)
3. Even-Sapir E, et al. J Nucl Med 2006; 47:287-297
4. Hillner B, et al. J Nucl Med 2014; 55:574-581
Key Messages
PET/CT is a powerful non-invasive diagnostic tool
Effective for: Detecting metastatic disease, restaging, identifying
biochemical relapse post-radical therapy, monitoring treatment
and primary staging generally limited to only high-risk disease
F-18 NaF imaging is an important tool for evaluating bone mets
Indications for using PET/CT in prostate cancer patients
Negative CT/MRI/SPECT bone scan and rising PSA
Radiation therapy planning
Staging of aggressive tumor types
F-18 FDG and F-18 fluciclovine show utility in detecting
local and/or regional and distant recurrence
References
www.NCCN.org Prostate Cancer Guidelines v.1.2016 accessed 3/8/16
Ceci F, Herrmann K, Castellucci P, et al. Impact of 11C-choline PET/CT on
clinical decision making in recurrent prostate cancer: results from a
retrospective two-centre trial. EJNMMI Dec 2014; 41(12):2222-2231
Even-Sapir, E. Imaging of Malignant Bone Involvement by morphologic,
scintigraphic, and hybrid modalities. J Nuc Med 2005; 46:1356-1367
Even-Sapir E, Metser U, Mishani E, et al. The detection of bone metastases
in patients with high-risk prostate cancer: 99mTc-MDP planar bone
scintigraphy, single- and multi-Field-of-View SPECT, 18F-fluoride PET, and
18F-fluoride PET/CT. J Nucl Med 2006; 47:287–297
References
Frederick DG, Fahey FH, Packard AB, et al. Skeletal PET with 18F-fluoride:
Applying new technology to an old tracer. J Nucl Med 2008; 49:68–78
Hillner B, Siegel B, Hanna L, et al. Impact of 18F-Fluoride PET in patients
with known prostate cancer: Initial results from the National Oncologic PET
Registry. J Nucl Med 2014; 55:574-581
Jadvar H. Molecular Imaging of Prostate Cancer with PET. J Nucl Med
2013; 54(10):1685-1688
McParland B, Wall A, Johansson S, and Sørensen J. The clinical safety,
biodistribution and internal radiation dosimetry of [18F]fluciclovine in healthy
adult volunteers. EJNMMI 2013; 40(8):1256–1264
Segall G, Delbeke D, Stabin M, et al. SNMMI Practice Guidelines for
Sodium 18F-Fluoride PET/CT Bone Scans 1.1. JNMMI 2010; 51(11):1813-
1820
References
Schirrmeister H, Guhlmann A, Kotzerke J,et al. Early detection and accurate
description of extent of metastatic bone disease in breast cancer with
fluoride ion and positron emission tomography. J Clin Oncol 1999;
17(8):2381-2389a
Schuster D, Votaw J, Nieh P, et al. Initial experience with the radiotracer
anti-1-amino-3-18F-fluorocyclobutane-1-carboxylic acid with PET/CT in
prostate carcinoma. J Nucl Med 2007; 48:56–63
Important Safety Information
Image interpretation errors can occur with PET imaging. A negative image
does not rule out recurrent prostate cancer and a positive image does not
confirm its presence. Clinical correlation, which may include
histopathological evaluation, is recommended.
The performance of F-18 fluciclovine and C-11 choline seem to be affected
by PSA levels. For F-18 fluciclovine, uptake may occur with other cancers
and benign prostatic hypertrophy in primary prostate cancer.
Hypersensitivity reactions, including anaphylaxis, may occur in patients who
receive PET radiopharmaceuticals. Emergency resuscitation equipment and
personnel should be immediately available.
PET/CT imaging contributes to a patient’s overall long-term cumulative
radiation exposure, which is associated with an increased risk of cancer.
Safe handling practices should be used to minimize radiation exposure to
the patient and healthcare providers.
Adverse reactions, although uncommon, may occur when using PET
radiopharmaceuticals. Always refer to the package insert prior to use.