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Nuclear Medicine

E2801. What’s New in the Molecular Imaging of Prostate Cancer? A Pictorial Review of Fluciclovine

Aminsharifi J,  Anderson S,  Banks K. San Antonio Military Medical Center, San Antonio, TX

Address correspondence to J. Aminsharifi (tidbit0@gmail.com)

Background Information: Prostate cancer is the second leading cause of cancer related death in men. While primary prostate cancer can usually be successfully treated, disease recurrence occurs in up to a third of patients. Recurrent disease is typically discovered by a rise in prostate specific antigen levels, but frequently the location and extent of recurrence cannot be accurately assessed. Anatomic imaging such as CT and magnetic resonance imaging (MRI) have suboptimal accuracy and traditional molecular imaging agents such as Fluorine-18 fluorodeoxyglucose (FDG) and Indium-111 capromab pendetide likewise suffer from poor sensitivity and specificity, respectively. Alternative molecular imaging agents such as Carbon-11 choline and C-11 acetate showed improved results, but were hindered from gaining widespread clinical use by the 20-minute half-life inherent to C-11. Fluciclovine, also known as anti-1-amino-3-18F-fluorocyclobutane-1-carboxylic acid, was recently developed to address the shortcomings of these imaging techniques. With its FDA approval in May of 2016, Fluciclovine PET will soon be seen for the first time. It is important for practitioners to familiarize themselves with this novel agent, its imaging technique and interpretation, as well as potential pitfalls that are already being recognized.

Educational Goals/Teaching Points: Participants will review the characteristics and clinical pharmacology of Fluciclovine F-18 and discuss its role in the management of prostate cancer and research supporting its efficacy and contrast the administration and image acquisition of Fluciclovine F-18 to FDG F-18. We review the interpretation criteria for Fluciclovine F-18 images in the setting of suspected recurrent prostate cancer.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: The mechanism of action of Fluciclovine F-18 is markedly different than prior molecular imaging studies such as FDG F-18 PET and Indium-111 capromab pendetide scintigraphy. These are compared and the role of amino acid transport regulation in cancer cells is discussed and graphically illustrated. Fluciclovine’s biodistribution at sites of recurrent disease and normal tissues is markedly different from that of the widely used FDG F-18. The effects on the administration and recommended imaging protocol of Fluciclovine F-18 are discussed and illustrated in a pictorial review as well as the criteria for interpretation of Fluciclovine F-18 PET scans in the setting of suspected recurrent prostate cancer. The diagnostic accuracy of Fluciclovine PET appears to be superior to anatomic and conventional molecular imaging studies. The studies supporting this are reviewed.

Conclusion: Fluciclovine F-18 is the first Food and Drug Administration–approved F-18 PET imaging agent for use in patients with suspected recurrent prostate cancer. Given the incidence of prostate cancer and the clinical utility of an F-18 labeled PET agent, it is likely that Fluciclovine will soon see widespread use. Its efficacy depends both on its inherent properties as well as the skill of those interpreting these novel examinations.