18F-Fluciclovine PET/CT performance in biochemical recurrence of prostate cancer: a systematic review

Abstract

Background A systematic literature review of the performance of 18Fluorine-fluciclovine PET/CT for imaging of men with recurrent prostate cancer was performed. Methods Scientific literature databases (MEDLINE, ScienceDirect and Cochrane Libraries) were searched systematically during Oct 2020 using PRISMA criteria. No limit was put on the date of publication. Prospective studies reporting a patient-level 18F-fluciclovine detection rate (DR) from ≥25 patients with recurrent prostate cancer were sought. Proceedings of relevant meetings held from 2018 through Oct 2020 were searched for abstracts meeting criteria. Results Searches identified 321 unique articles. In total, nine articles (six papers and three conference abstracts), comprising a total of 850 patients met inclusion criteria. Most studies (n = 6) relied on ASTRO-Phoenix Criteria, EAU-ESTRO-SIOG, and/or ASTRO-AUA guidelines to identify patients with biochemical recurrence. Patients’ PSA levels ranged from 0.02–301.7 ng/mL (median level per study, 0.34–4.10 ng/mL [n = 8]). Approximately 64% of patients had undergone prostatectomy, but three studies focused solely on post-prostatectomy patients. Adherence to imaging protocol guidelines was heterogeneous, with variance seen in administered activity, uptake and scan times. Overall patient-level DR varied between studies from 26% to 83%, with 78% of studies reporting a DR > 50%. DR was proportional to PSA, but even at PSA < 0.5 ng/mL DR of up to 53% were reported. Prostate/bed DR (n = 7) ranged from 18% to 78% and extra-prostatic rates (n = 6) from 8% to 72%. Pelvic node and bone lesion DR ranged from 8% to 47% and 0% to 26%, respectively (n = 5). 18F-Fluciclovine PET/CT was shown to impact patient management and outcomes. Two studies reported 59–63% of patients to have a management change post-scan. A further study showed significant increase in failure-free survival following 18F-fluciclovine-guided compared with conventional imaging-guided radiotherapy planning. Conclusions 18F-Fluciclovine PET/CT shows good performance in patients with recurrent prostate cancer leading to measurable clinical benefits. Careful adherence to recommended imaging protocols may help optimize DR.

Impact of 18F-fluciclovine PET/CT on salvage radiotherapy plans for men with recurrence of prostate cancer postradical prostatectomy

“…The authors noted the difference was attributable to prostate/bed findings (18% vs. 71%, respectively) [7] and this is supported by the present analysis. The influence of PSA on localisation of biochemical recurrence of prostate cancer with 18 F-fluciclovine PET/CT has been demonstrated previously [6]. While undetectable PSA levels might be expected soon after radical prostatectomy, it can take years to achieve a nadir PSA level with radiotherapy, and in some patients, PSA levels rise temporarily postradiotherapy in a phenomenon referred to as 'PSA bounce' [14,15].…”

“…An analysis by Kim et al [7] has shown that 18 F-fluciclovine PET/CT specifically may be a useful tool to guide targeted treatment of oligometastases. Thus, while recent data suggest that sensitive PSMA-based PET/CT may become the imaging modality of choice to direct treatment for patients with oligometastatic disease [23], emerging data on the performance of 18 F-fluciclovine PET/CT at low PSA levels [18] suggest it should not be overlooked. Our data show that approximately half of patients with 18 F-fluciclovine-avid lesions showed positivity outside the prostate bed, with the extent of spread rising with increasing PSA levels.…”

“…For patients who had radiotherapy or brachytherapy as primary therapy, biochemical recurrence was diagnosed as a PSA increase of ≥2.0 ng/mL above the nadir. Patients who had received androgen-deprivation therapy (ADT) or had undergone choline PET/ CT ≤3 months before screening were excluded as were any patients who had received another investigational product from 1 month before to 1 week after 18 F-fluciclovine PET/ CT, any patients with known 18 F-fluciclovine hypersensitivity or any with bilateral hip prostheses. 18 F-Fluciclovine PET/CT was conducted and interpreted at each site in accordance with standard procedures [12].…”

“…6 presents how the extent of metastatic spread influenced the management decisions. Following a negative 18 F-fluciclovine PET/CT (n = 41), clinicians most commonly did not revise the prescan plan (33/41, 80%). However, 8 patients (20%) with a negative scan had a change to their planned treatment modality postscanfrequently to abort salvage radiotherapy in favour of active surveillance (6/8, 75%).…”

“…The advent of molecular imaging yields potential for more reliable localisation of local and metastatic disease to inform radiotherapy plans. 18 F-Fluciclovine is a positron emission tomography (PET) radiotracer that is approved in the US and Europe for the detection of sites of prostate cancer recurrence [6]. 18 F-Fluciclovine PET/CT shows good diagnostic performance across a wide range of PSA values [6] and maybe a useful tool in identifying patients with oligometastatic disease [7].…”