Clinical PET Imaging in Prostate Cancer

Targeted CE per ARRT’s Discipline, Category, and Subcategory classification:
[Note: Discipline-specific Targeted CE credits may be less than the total Category A credits approved for this course.]

Nuclear Medicine Technology: 1.75
Procedures: 1.75
Radionuclides and Radiopharmaceuticals: 0.25
Endocrine and Oncology Procedures: 1.50

Registered Radiologist Assistant: 1.00
Procedures: 1.00
Abdominal Section: 1.00

Radiation Therapy: 1.00
Patient Care: 1.00
Patient and Medical Record Management: 1.00

Outline

1. Introduction
2. Current Conventional Imaging Strategy for Prostate Cancer
   1. Initial Staging
   2. Restaging after Biochemical Relapse
   3. Response Assessment
   4. PET Imaging Agents
3. Fluorodeoxyglucose
   1. Localization of Primary Tumor
   2. Staging
   3. Biochemical Relapse
   4. Response Assessment
   5. Prognosis
   6. Summary
4. ¹¹C-Choline and ¹⁸F-Choline
   1. Localization of Primary Tumor
   2. Staging
   3. Biochemical Relapse
   4. Response Assessment and Prognosis
   5. Summary
5. ⁶⁸Ga Prostate-Specific Membrane Antigen
   1. Localization and Staging
   2. Biochemical Relapse
   3. Summary
6. ¹⁸F-Fluciclovine
   1. Localization of Primary Tumor
   2. Staging
   3. Biochemical Relapse
   4. Summary
7. ¹⁸F-Sodium Fluoride
   1. Staging
   2. Response Assessment of Osseous Metastases
   3. Summary
8. Conclusion

Objectives

Upon completion of this course, students will:

1. know the imaging modalities that are considered to be the conventional imaging techniques for prostate imaging
2. be familiar with the various acronyms that are utilized both within this article and for prostate cancer management in general
3. know how prostate cancer is typically diagnosed and risk stratified
4. know the limitations of conventional imaging of prostate cancer assessment
5. be familiar with the current uses of multiparametric MR imaging of the prostate before biopsy
6. understand the reasons behind the necessity for the accurate detection of prostate cancer bone metastases
7. be familiar with the AUA and NCCN guidelines for recommending bone scintigraphy for staging of prostate cancer
8. be familiar with the ASTRO definitions of biochemical relapse, both after radical prostatectomy and after radical radiation therapy
9. be familiar with the various PET tracer options for prostate cancer imaging and the particular role that each can serve
10. recognize the limited treatment options for castration-resistant prostate cancer
11. be able to identify some issues with the current response criteria for conventional imaging when evaluating prostate cancer treatment response
12. be familiar with FDG and its metabolic pathway in the body
13. know the suggested patient preparation, uptake times, and scan FOVs for the tracers discussed in the article
14. understand the disadvantages and limited usefulness of FDG in the imaging of primary prostate cancers
15. know the possible use case for FDG in prostate cancer staging
16. be familiar with the results of a study of patients with biochemical relapse in whom FDG PET was performed before pelvic nodal dissection
17. be familiar with some of the potential roles of FDG PET/CT in prostate cancer response assessment
18. understand the reported significance of FDG PET/CT to prostate patients’ prognoses
19. understand the significance of intraprostatic FDG uptake at preoperative staging
20. know the advantages and disadvantages when comparing ¹¹C-choline and ¹⁸F-choline tracer options for PET imaging of prostate cancer
21. be able to identify the method used by some institutions using ¹⁸F-choline to help distinguish prostate bed or nodal recurrence from adjacent physiologic urinary activity
22. understand where choline PET/CT may be useful in the localization of primary prostate tumors
23. know which imaging modalities use size criteria and nodal morphologic structure for evaluating nodal metastases
24. understand choline PET/CT’s potential usefulness in staging despite its moderate sensitivity for nodal staging according to the PET guidelines of the Royal College of Radiologists and Royal College of Physicians
25. know choline PET/CT’s usefulness in prostate bone metastases evaluation
26. know when choline PET/CT is most accurate in cases of biochemical relapse
27. understand the influence that PSA has on ¹¹C-choline assessments of biochemical relapse
28. know what PSA measurement(s) should be accounted for when considering the use of choline PET/CT
29. be familiar with the NCCN and EAU guideline recommendations for choline PET/CT in situations of biochemical relapse
30. Understand the findings from studies using choline PET/CT in prostate cancer response assessment
31. be familiar with PSMA expression
32. be familiar with the newer generation of ⁶⁸Ga-PSMA ligands
33. be able to identify locations of physiologic biodistribution of ⁶⁸Ga-PSMA
34. know how physiologic urinary activity can affect ⁶⁸Ga-PSMA image interpretation
35. know when ⁶⁸Ga-PSMA imaging is indicated according to joint procedure guidelines from the EANM and SNMMI
36. know how ⁶⁸Ga-PSMA PET/CT compared with CT/MR imaging in a study of 130 patients with intermediate- to high-risk prostate cancer being evaluated for nodal involvement
37. recognize the advantages of ⁶⁸Ga-PSMA PET/CT over ¹¹C-Choline PET/CT when evaluating for prostate cancer biochemical relapse
38. be able to identify some examples of targeted therapies for intraprostatic disease
39. understand the suggestions of the joint procedure guidelines from the EANM and SNMMI about ⁶⁸Ga-PSMA PET/CT imaging usefulness in biochemical relapse
40. know the benefits of ¹⁸F-fluciclovine in prostate cancer imaging
41. know what most investigators to date advise for patient preparation and image acquisition with ¹⁸F-fluciclovine
42. be familiar with the advantages and FDA approved usage of ¹⁸F-fluciclovine
43. know what ¹⁸F-sodium fluoride uptake correlates with
44. know how, despite uptake in benign degenerative and inflammatory lesions, ¹⁸F-sodium fluoride PET/CT can have higher specificity than planar bone scintigraphy
45. understand why ¹⁸F-sodium fluoride PET/CT is not being routinely recommended over traditional bone scintigraphy and other PET tracers