Abstract
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 discussions. However, because no standardized grading system or templates yet exist for 18F-fluciclovine image assessment, reports vary in format, comprehensiveness, and terminology and may be challenging to fully understand. To better utilize these documents, referring physicians should be aware of six key features of 18F-fluciclovine PET/CT. First, 18F-fluciclovine is a radiolabeled synthetic amino acid targeting the amino acid transporters ASCT2 and LAT1, which are ubiquitous throughout the body, but overexpressed in prostate cancer. Second, 18F-fluciclovine image interpretation is predominantly visual/qualitative: radiotracer uptake in suspicious lesions is compared with uptake in bone marrow or blood pool. Location of 18F-fluciclovine-avid lesions relative to typical recurrence sites and findings elsewhere in the patient are considered when evaluating lesions' probability of malignancy, as is visibility on maximum intensity projection images when assessing bone lesions. Third, 18F-fluciclovine PET/CT detection rates increase as PSA levels rise. Fourth, detection rates may differ among centers, possibly due to equipment and reader experience. Fifth, since no diagnostic test is 100% accurate, scan data should not be used in isolation. Lastly, 18F-fluciclovine PET/CT findings frequently induce changes in disease management plans. In the prospective multicenter LOCATE and FALCON studies, scans altered management plans in 59% (126/213) and 64% (66/104) of patients, respectively; 78% (98/126) and 65% (43/66) of changes, respectively, involved modality switches. Referring physicians and imagers should collaborate to improve scan reports. Referrers should clearly convey critical information, including prescan PSA levels, and open clinical questions. Imagers should produce reports that read like consultations, avoid leaving open questions, and if needed, provide thoughts on next diagnostic steps.
Highlights
For physicians treating men with suspected biochemical recurrence of prostate cancer, and for their patients, detecting sites of relapse and characterizing extent of disease provide crucial information for treatment planning
® ylic acid (18F-FACBC), Axumin, Blue Earth Diagnostics, Burlington, MA) was approved in the US in May 2016 as a tracer for “positron emission tomography (PET) imaging in men with suspected prostate cancer recurrence based on elevated blood prostate-specific antigen (PSA) levels” posttreatment [3]
While standardized procedures exist for 18F-fluciclovine PET/computed tomography (CT) image acquisition [3, 6] and image interpretation [6,7,8], no standardized grading system or templates have been introduced for 18F-fluciclovine PET/CT reporting
Summary
For physicians treating men with suspected biochemical recurrence of prostate cancer, and for their patients, detecting sites of relapse and characterizing extent of disease provide crucial information for treatment planning. A third prospective study, reported in 2019 [21, 22], involved 21 consecutive nonprostatectomy patients with rising PSA (median (minimum − maximum) 4.5 (1.0–26.7) ng/mL) after definitive treatment with radiotherapy (43%), cryotherapy (14%), or both (43%) In this small, singlecenter trial, the detection rate for disease in the prostate for experimental 18F-fluciclovine PET/CT/ultrasound fusion biopsy was 48% (10/21 patients). In another prospective study [1] with 74% (69/93) nonprostatectomy patients, 18F-fluciclovine PET/CT sensitivity and specificity, respectively, were 90% and 40% in the prostate/prostate bed (n 91) and 55% and 97% for extraprostatic disease (n 70) Both referring physicians and imagers can help improve the quality of 18F-fluciclovine PET/CT reports. A 1.4 cm lymph node, identified on the correlative CT portion of the study (axial image 236).” For referring physicians wishing access to all scan data, Health Insurance Portability and Accountability Act-compliant connectivity tunnels can be established for image/data transfer; for those wishing selected data, studies can be placed on disk, typically including an embedded program for reading
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