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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
 National Comprehensive Cancer Network (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), prostate-specific antigen (PSA) begins
rising again but the cancer is not (yet) detected by CT or MRI
 Treatment monitoring
 Use for primary staging generally limited to only high-risk
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 noninformative 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 (NOTE: FDA approved fluciclovine May 2016; it is
not yet included in the NCCN guidelines.) NCCN Guidelines Prostate Cancer, Version 1.2016 accessed 3/8/16
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 from these guidelines.
**Please consult the NCCN website for their complete set of guidelines.** 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
PET/CT in Prostate Cancer:
Benefits of C-11 Choline Imaging
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.
Results: C-11 choline-PET/CT revealed both soft tissue and
osseous multifocal metastases
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
Even-Sapir E, et al. J Nucl Med 2006; 47:287–297
PET/CT in Prostate Cancer:
F-18 NaF Imaging Data
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
Planar bone scan
Even-Sapir E, et al. J Nucl Med 2006; 47:287–297
PET/CT in Prostate Cancer:
F-18 NaF and NOPR
 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
Hillner B, et al. J Nucl Med 2014; 55:574-581
Impact of F-18 NaF on Prostate
Cancer Management
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
PET/CT in Prostate Cancer Recurrence:
Imaging with F-18 Fluciclovine
PET (A) and PET/CT (B) image of fluciclovine in
a man with biopsy-proven recurrence in the
prostate bed. (Schuster et al. J Nucl Med 2007; 48:56–63)
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/CT in Prostate Cancer:
Image-Guided Radiotherapy Planning
F-18 fluciclovine imaging can be used to plan
radiotherapy treatment
A. Original radiotherapy
(Rx) treatment plan
B. Fluciclovine imaging
results reveal iliac lymph
node involvement
C. Revised treatment
plan now includes
involved LN
The color scale ranges from radiotherapy dose of 0 to 77 Gy.
Schreibmann E, et al. Int J Rad Onco 2016
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
1. Ceci F, et al. EJNMMI 2014; 41(12):2222-2231
2. Schreibmann E, et al. J Rad Onc Biol Phys 2016,
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
 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
 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
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):18131820
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;
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 may be 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.