International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationDetection of Local, Regional, and Distant Recurrence in Patients With PSA Relapse After External-Beam Radiotherapy Using 11C-Choline Positron Emission Tomography
Introduction
A rise in prostate-specific antigen (PSA) is usually the first sign of recurrent prostate cancer after curative treatment. Biochemical recurrence (BCR) following radiotherapy has been defined by the American Society for Therapeutic Radiology and Oncology (ASTRO) (1) and recently updated in the ASTRO Phoenix Consensus (2).The time interval between treatment and BCR as well as PSA doubling time are used as indicators for local or distant recurrence (3). Conventional imaging modalities such as CT and MRI are limited in their ability to localize the site of recurrence with high accuracy (4). Transrectal ultrasound and biopsies may identify local recurrences, but these techniques do not give information about the possible presence of locoregional and distant metastases (4). This means that clinical decision making with respect to salvage treatments such as prostatectomy, cryoablation, or high-intensity focused ultrasound (HIFU) is not possible.
To select patients for salvage radiotherapy for recurrence after prostatectomy, the 111In-capromab pendetide scintigraphy (Prostascint) has been used 5, 6. There are no data about the efficacy of this type of scintigraphy in cases of recurrence after external-beam radiotherapy (EBRT). Molecular imaging techniques such as positron emission tomography (PET) and single photon emission computed tomography have proved to be valuable in the restaging of many tumors.
This study was conducted to determine the accuracy of 11C-choline PET in detecting the site of recurrence in patients with BCR after EBRT and to correlate these findings with clinical parameters.
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Patients
This prospective study concerned patients at follow-up after EBRT for histological proven prostate cancer. They were eligible if they fulfilled ASTRO 1997 criteria for BCR. Patients who had adjuvant hormonal therapy within 1 year from the start of the study were excluded. Ten patients without BCR after EBRT served as a control group.
The patients with BCR were subsequently treated according to current guidelines on prostate cancer. From 2007 on, we offered salvage cryoablation to patients with a
Results
Seventy patients were included. The patient characteristics at the time of 11C-choline PET, with a median PSA of 10.7 ng/mL (range, 0.6–54.7 ng/mL) are summarized in Table 1.
Fifty-seven of 70 (81%) patients with a BCR proved true positive for local recurrence and/or locoregional and/or distant metastases. Results are presented in Table 2. Two typical examples are shown in Fig. 1, Fig. 2. The 10 control patients with a median serum PSA of 0.95 ng/mL (range, <0.1–6.3 ng/mL) did not show any
Discussion
This study shows that 11C-choline PET is a sensitive technique to detect the site of recurrence in patients with a rising PSA after EBRT. Local recurrences and regional and/or distant metastases can be identified with an overall sensitivity of 81%. With the improvement and increased clinical use of local salvage therapies such as cryoablation and HIFU, restaging of prostate cancer after EBRT has become an important issue 7, 10.
In general, serum PSA levels are used to indicate recurrence, but
Conclusion
11C-choline PET scan is a sensitive and accurate imaging technique to identify the site of recurrence in patients with PSA relapse after EBRT for prostate cancer.
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Conflict of interest: none.