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[18F]DCFPyL PET/CT in Detection and Localization of Recurrent Prostate Cancer Following Prostatectomy Including Low PSA  0.5 ng/mL - Beyond the Abstract

The aim of this retrospective multicenter analysis was to assess the performance of [18F]DCFPyL prostate-specific membrane antigen (PSMA) PET/CT in the detection and localization of recurrent prostate cancer following radical prostatectomy (RP). Although the use of PSMA PET/CT in biochemical failure post-prostatectomy has been validated by international literature as being superior to conventional imaging1,2 and having a significant impact on management,2-8 the recommendation for its use in prostate cancer guidelines is heterogeneous and therefore public funding for this investigative pathway is limited.9-13 Specifically, PSMA PET/CT is not publicly funded for this indication in Australia and is only publicly available in one region of New Zealand but only when prostate-specific antigen (PSA) is above 0.5ng/mL. Conversely, PSMA PET/CT is widely available for those with insurance although some providers only approve above a PSA threshold. Given prostate cancer is the most commonly diagnosed cancer and is the second-highest cause of all cancer deaths in Australia, lack of access to PSMA PET/CT may adversely affect the outcome in these patients.14,15 Particular reference is given to low PSA groups < 0.5 ng/mL in our study to aid discussion around the inclusion of this group in international guidelines and funding pathways.


Our study is the largest to date examining [18F]DCFPyL PET/CT in biochemical failure with particular reference to patients with PSA < 0.5 ng/mL. We included 222 patients with biochemical failure who underwent [18F]DCFPyL PET/CT at two sites in Australia and New Zealand. 46.4% (103/222) of these patients had PSA <0.5ng/mL. Within this group, we found a significant number had disease beyond the prostate bed, either with involved pelvic nodes (23.3%) or extra pelvic disease (13.6%) [Figure 1].

Distribution of individual lesions with increased PSMA expression

Figure 1. Distribution of individual lesions with increased PSMA expression for patients with PSA < 0.5ng/mL.

The incidence of pelvic nodal and extra pelvic metastases increased with PSA level. The number of positive PSMA studies, however, was similar in the <0.5ng/mL group (59.2%) and the 0.5-0.99ng/mL group (62.8%) [Table 1].

Table 1. Site of disease recurrence stratified by PSA group 

Site of disease recurrence stratified by PSA group

Our data suggests that recurrent prostate cancer is frequently detectable by [18F]DCFPyL PET/CT even in low PSA groups. Our results are similar to studies using 68Ga PSMA and to other studies using [18F]DCFPyL PET/CT but with smaller numbers.4,16-20

We would recommend validating these findings with a prospective study that aims to examine the impact on management decisions in this cohort. In this regard, we await data from the current IMPPORT trial.21 Future directions may involve assessment of any incremental value of PET/MRI imaging in those with biochemical failure with recent data suggesting increased detection rate of local recurrence at low PSA levels using this modality and follow-up of  [18F]DCFPyL staged patients receiving salvage radiotherapy.22

Written by: Elisa Perry, Arpit Talwar, Kim Taubman, Michael Ng, Lih-Ming Wong, Russell Booth, Tom R Sutherland

Pacific Radiology, Christchurch, Canterbury, New Zealand., Department of Medical Imaging, St. Vincent's Hospital, Melbourne, Victoria, Australia., GenesisCare, St. Vincent's Hospital, Melbourne, Victoria, Australia., Department of Urology, St. Vincent's Hospital, Melbourne, Victoria, Australia.

References:

  1. Tanaka, Takashi, Ming Yang, Adam T. Froemming, Alan H. Bryce, Ryota Inai, Susumu Kanazawa, and Akira Kawashima. "Current imaging techniques for and imaging spectrum of prostate cancer recurrence and metastasis: a pictorial review." RadioGraphics (2020): 190121.
  2. Hope, Thomas A., Rahul Aggarwal, Bryant Chee, Dora Tao, Kirsten L. Greene, Matthew R. Cooperberg, Felix Feng, et al. “Impact of 68Ga-PSMA-11 PET on Management in Patients with Biochemically Recurrent Prostate Cancer.” Journal of Nuclear Medicine 58, no. 12 (December 1, 2017): 1956. 
  3. Roach, Paul J., Roslyn Francis, Louise Emmett, Edward Hsiao, Andrew Kneebone, George Hruby, Thomas Eade et al. "The impact of 68Ga-PSMA PET/CT on management intent in prostate cancer: results of an Australian prospective multicenter study." Journal of Nuclear Medicine 59, no. 1 (2018): 82-88.
  4. Song, Hong, Caitlyn Harrison, Heying Duan, Kip Guja, Negin Hatami, Benjamin L. Franc, Farshad Moradi, Carina Mari Aparici, Guido A. Davidzon, and Andrei Iagaru. "Prospective Evaluation of 18F-DCFPyL PET/CT in Biochemically Recurrent Prostate Cancer in an Academic Center: A Focus on Disease Localization and Changes in Management." Journal of Nuclear Medicine 61, no. 4 (2020): 546-551.
  5. Bashir, Usman, Alison Tree, Erik Mayer, Daniel Levine, Chris Parker, David Dearnaley, and Wim JG Oyen. "Impact of Ga-68-PSMA PET/CT on management in prostate cancer patients with very early biochemical recurrence after radical prostatectomy." European journal of nuclear medicine and molecular imaging 46, no. 4 (2019): 901-907.
  6. Emmett, Louise, Pim J. van Leeuwen, Rohan Nandurkar, Matthijs J. Scheltema, Thomas Cusick, George Hruby, Andrew Kneebone et al. "Treatment outcomes from 68Ga-PSMA PET/CT–informed salvage radiation treatment in men with rising PSA after radical prostatectomy: prognostic value of a negative PSMA PET." Journal of Nuclear Medicine 58, no. 12 (2017): 1972-1976.
  7. Farolfi, Andrea, Francesco Ceci, Paolo Castellucci, Tiziano Graziani, Giambattista Siepe, Alessandro Lambertini, Riccardo Schiavina, Filippo Lodi, Alessio G. Morganti, and Stefano Fanti. "68 Ga-PSMA-11 PET/CT in prostate cancer patients with biochemical recurrence after radical prostatectomy and PSA< 0.5 ng/ml. Efficacy and impact on treatment strategy." European journal of nuclear medicine and molecular imaging 46, no. 1 (2019): 11-19.
  8. Schmidt-Hegemann, Nina-Sophie, Christian Stief, Tak-Hyun Kim, Chukwuka Eze, Simon Kirste, Iosif Strouthos, Minglun Li et al. "Outcome after PSMA PET/CT–based salvage radiotherapy in patients with biochemical recurrence after radical prostatectomy: a 2-institution retrospective analysis." Journal of Nuclear Medicine 60, no. 2 (2019): 227-233.
  9. NICE. Guidance 2019 prostate cancer: diagnosis and management. BJU Int. 2019;124:9–26.
  10. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Prostate Cancer Version 3.2020. 2020. [7 Dec 2020]. Available from: https://www.nccn.org/ professionals/physician_gls/pdf/prostate.pdf.
  11. New Zealand Ministry of Health. NZ National Indicators for PETCT. Wellington: Ministry of Health; 2018.
  12. The, Royal College Of Radiologists, College Of Physicians Of London Royal, College Of Physicians Royal, Royal College of Physicians of Edinburgh, and Administration Of Radioactive Substances Advisory Committee. "Evidence-based indications for the use of PET-CT in the United Kingdom 2016." Clinical radiology 71, no. 7 (2016): e171.
  13. Trabulsi, Edouard J., R. Bryan Rumble, Hossein Jadvar, Thomas Hope, Martin Pomper, Baris Turkbey, Andrew B. Rosenkrantz et al. "Optimum imaging strategies for advanced prostate cancer: ASCO guideline." Journal of Clinical Oncology (2020): JCO-19.
  14. Australian Institute of Health and Welfare. Cancer in Australia. 2019. [4 August 2020]. Available from: www.aihw.gov.au/ reports/cancer/cancer-in-australia-2019/contents/summary. Accessed 7 Dec 2020.
  15. Siegel, Rebecca L., Kimberly D. Miller, and Ahmedin Jemal. "Cancer statistics, 2019." CA: a cancer journal for clinicians 69, no. 1 (2019): 7-34.
  16. Markowski, Mark C., Ramy Sedhom, Wei Fu, Javaughn Corey R. Gray, Mario A. Eisenberger, Martin G. Pomper, Kenneth J. Pienta, Michael A. Gorin, and Steven P. Rowe. "PSA and PSA Doubling Time Predict Findings on 18F-DCFPyL PET/CT in Patients with Biochemically-Recurrent Prostate Cancer." The Journal of Urology (2020): 10-1097.
  17. Rowe, Steven P., Scott P. Campbell, Margarita Mana-Ay, Zsolt Szabo, Mohamad E. Allaf, Kenneth J. Pienta, Martin G. Pomper, Ashley E. Ross, and Michael A. Gorin. "Prospective evaluation of PSMA-targeted 18F-DCFPyL PET/CT in men with biochemical failure after radical prostatectomy for prostate cancer." Journal of Nuclear Medicine 61, no. 1 (2020): 58-61.
  18. Wondergem, M., B. H. E. Jansen, F. M. van der Zant, T. M. van der Sluis, R. J. J. Knol, L. W. M. van Kalmthout, O. S. Hoekstra, R. J. A. van Moorselaar, D. E. Oprea-Lager, and A. N. Vis. "Early lesion detection with 18 F-DCFPyL PET/CT in 248 patients with biochemically recurrent prostate cancer." European journal of nuclear medicine and molecular imaging 46, no. 9 (2019): 1911-1918.
  19. Perera, M., N. Papa, M. Williams, M. Roberts, C. Udovicic, I. Vela, D. Bolton, N. Lawrentschuk, and D. Murphy. "68 Ga-PSMA PET in advanced prostate cancer updated diagnostic utility, sensitivity and specificity and distribution of PSMA-avid lesions systematic review and meta-analysis." Bju International 123 (2019): 45-45.
  20. Fendler, Wolfgang P., Jeremie Calais, Matthias Eiber, Robert R. Flavell, Ashley Mishoe, Felix Y. Feng, Hao G. Nguyen et al. "Assessment of 68Ga-PSMA-11 PET accuracy in localizing recurrent prostate cancer: a prospective single-arm clinical trial." JAMA oncology 5, no. 6 (2019): 856-863.
  21. IMPPORT trial (Australian Clinical Trials Registry Number 12618001530213). Available from: http://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=375932. Accessed 7th August 2020.
  22. Evangelista, Laura, Fabio Zattoni, Gianluca Cassarino, Paolo Artioli, Diego Cecchin, Fabrizio Dal Moro, and Pietro Zucchetta. "PET/MRI in prostate cancer: a systematic review and meta-analysis." European Journal of Nuclear Medicine and Molecular Imaging (2020): 1-15.
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