ramathibodi ga-68 psma cases - mahidol university · pet tracers for prostate cancer f-18 naf f-18...
TRANSCRIPT
![Page 1: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/1.jpg)
Ramathibodi Ga-68 PSMA cases
ผศ. พญ. วชิชนา จํารูญรัตน์
Wichana Chamroonrat, MD9 Nov 2018
Adapted from “Prostate cancer update” on 14 Jun 2017
“Thai SNM meeting” on 15 Dec 2017
“RT topic” dated 16 May 2018
![Page 2: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/2.jpg)
PSMA
• Prostate Specific Membrane Antigen
• Overexpressed 100-1000times in PC compared to normal prostate tissues
• Expressed in normal tissues as salivary glands, duodenal mucosa, proximal renal tubular cells, colonic crypt
• Overexpressed in TCC, RCC, colon CA, (thyroid) endothelial cell of neovasculature
![Page 3: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/3.jpg)
Increased PSMA expression: Prostate CA
• Increased tumor grade
• Pathologic stage
• Aneuploidy
• Biochemical recurrence
• Up-regulated when androgen independent
– Early indicator for tumor progression after ADT
– Prognostic factor for disease recurrence
– CRPC and metastatic PC
![Page 4: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/4.jpg)
PET tracers for Prostate cancer
F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA
Tc-99m MDP
*References: PET clinics, Calabria F et.al NMB 2017
* *
F-18 FDG Ga-68 PSMA
Commercially available for prostate cancerDx F-18 PSMARx Lu-177 PSMA
![Page 5: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/5.jpg)
![Page 6: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/6.jpg)
2018 Urology Clinic of North America
![Page 7: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/7.jpg)
![Page 8: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/8.jpg)
Ga-68 PSMA
• Dose 0.05-0.06mCi/kg
• Furosemide 20mg IV immediate after Ga-68 PSMA
• Uptake time 1hour
• Philips Gemini TF CT 64slides
• 2min/bed position
• 500cc plain water within 2hours prior scanning
• Urinate prior scanning
![Page 9: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/9.jpg)
27scans(24patients)
23pt Prostate CA
6staging 17restaging
1pt
Pancreatic CA
14 Sep 2017 – 4 Oct 2018
![Page 10: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/10.jpg)
Display favor FDG reading
FDG PSMA
![Page 11: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/11.jpg)
More suitable for PSMA
FDG PSMA
![Page 12: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/12.jpg)
Staging of locally advanced case with diuretic
but different display setting
![Page 13: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/13.jpg)
Two negative PSMA casesboth: NO underling of renal impairment
NO diuretic WITH diuretic
![Page 14: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/14.jpg)
• Primary staging in high risk disease before Sxor RT
– GS >7, PSA >20, clinical stage T2-3a
– Increase likelihood of LN and bone metastases.
– Can replace abdomen CT for nodal metastasis.
– Can’t replace pelvic MRI for local tumor delineation.
– Bone scan may add value in PSMA negative tumor or densely sclerotic bone lesion.
Ga-68 PSMA AUC by SNMMI EANM
AUC: Appropriate Use CriteriaReferences: Fendler WP EJNM 2017
![Page 15: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/15.jpg)
27scans(24patients)
23pt Prostate CA
6staging 17restaging
1pt
Pancreatic CA
14 Sep 2017 – 4 Oct 2018
![Page 16: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/16.jpg)
6staging
4single scan
31incidental thyroid CA
2FU
Rx response
14 Sep 2017 – 4 Oct 2018
![Page 17: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/17.jpg)
65M PSMA PSA 13.16ng/ml, Cr 0.99mg/dlBx GS10
ST
![Page 18: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/18.jpg)
ST
75M PSMA PSA 67ng/ml, Cr 1.07mg/dlBx GS 8
![Page 19: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/19.jpg)
61M PSMA PSA 4.34ng/ml, Cr 0.9mg/dlBx GS3+4, plan surgery
GS 7
ST
![Page 20: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/20.jpg)
ST
59M PSMA PSA 0.013ng/ml, Cr 0.98mg/dlPost radical prostatectomy, GS4+5
R L
![Page 21: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/21.jpg)
63M PSMA PSA 0.108-21.25ng/ml, Cr 0.9-1.1 mg/dlPost radical prostatectomy, GS9, on ADT (PSA 189 pre ADT)
Initial PSA 21.25
Follow upPSA 0.108
ST+Res
![Page 22: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/22.jpg)
77M PSMA PSA 4.24-7.28 ng/ml, Cr 0.68-0.76mg/dlPost TURP, GS10
Initial PSA 7.28
Follow upPSA 4.24
ST+Res
![Page 23: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/23.jpg)
6staging (PSA)
4+ scan
1 Primary only:
67
3 primary+other
Avg 69.81
(7.28-189)
2-
-Post RP: 0.013 (+PTC)
-GS7, subcm: 4.34
14 Sep 2017 – 4 Oct 2018
![Page 24: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/24.jpg)
• Localization of tumor tissue in recurrence prostate cancer
– PSA0.2-10ng/ml
– Higher sensitivity with shorter doubling time
– Higher initial Gleason score
Ga-68 PSMA AUC by SNMMI EANM
AUC: Appropriate Use CriteriaReferences: Fendler WP EJNM 2017
![Page 25: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/25.jpg)
Ga-68 PSMA PET
• Meta-analysis 16articles and 1309patients
• Positive Ga-68 PSMA PET 76% with biochemical recurrence
Detection rate
• PSA 0-0.2 = 42%
• PSA 0.2-1 = 58%
• PSA 1-2 = 76%
• PSA >2 = 95%
References: Perera M EU 2016
![Page 26: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/26.jpg)
27scans(24patients)
23pt Prostate CA
6staging 17restaging
1pt
Pancreatic CA
14 Sep 2017 – 4 Oct 2018
![Page 27: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/27.jpg)
17restaging
biochemical recurrence
10positive
2known8
(1with FU)
7negative
14 Sep 2017 – 4 Oct 2018
![Page 28: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/28.jpg)
FDG PET 6 mo prior
Bone scan 10mo prior
80M PSMA rising PSA 100+ ng/ml, Cr ? mg/dlProstate cancer with known bone met post bilateral orchidectomy
BR
![Page 29: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/29.jpg)
75M PSMA PSA 0.582ng/ml, Cr 0.9mg/dlCRPC post Abiraterone (pre PSA 25.17)
Bone scan 1.5 years ago
BR+Res
![Page 30: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/30.jpg)
77M PSMA PSA 2.22-2.71ng/ml, Cr 0.98-1.11mg/dlPost radical prostatectomy, and RT, on ADT, GS8
Before PSA 2.22
Follow upPSA 2.71
BR+Res
![Page 31: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/31.jpg)
80M PSMA PSA 30.67ng/ml, Cr 0.73mg/dlPost radical prostatectomy
BR
![Page 32: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/32.jpg)
Bone scan 4mo prior
68M PSMA rising PSA 32.38 ng/ml, Cr 0.98 mg/dlProstate CA post RP >10yr with local recurrence
BR
![Page 33: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/33.jpg)
WITH diuretic
60M PSMA rising PSA 1.54 ng/ml, Cr 1 mg/dlProstate CA post brachytherapy and external RT 5 years on ADT
BR
+node FNA SBRT, later PSA 0.3
![Page 34: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/34.jpg)
78M PSMA PSA 5.36ng/ml, Cr 1.18mg/dlBx GS3+3 with rectal cancer post CCRT and APR
?insuff Fx?
BR
Eq
![Page 35: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/35.jpg)
85M PSMA PSA 14.1ng/ml, Cr 1.09mg/dlBx 2012 on ADT, PSA rising
BR
Pri
![Page 36: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/36.jpg)
82M PSMA PSA 5.63ng/ml, Cr 0.92mg/dlProstate and urinary bladder cancer
BR
Pri
![Page 37: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/37.jpg)
66M PSMA PSA 9.66ng/ml, Cr 0.77mg/dlDx 2008 post RT and ADT
BR
Pri
![Page 38: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/38.jpg)
17restaging (PSA)
biochemical recurrence
10positive
Primary(3) No&Dis(7)
Avg 9.79
Min 5.63
Max 14.1
Avg 24.68
Min 0.582
Max >100
7negative
Avg 0.34
Min 0.003
Max 0.83
14 Sep 2017 – 4 Oct 2018
Equivocal insuff FxPSA 5.36, GS6
![Page 39: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/39.jpg)
Emerging clinical applications
• Staging before or during PSMA directed radiotherapy (e.g. Lu-177 PSMA)
• Targeted biopsy after previous negative biopsy in patients with high suspicion of prostate cancer
• Monitoring of systemic treatment in metastatic prostate cancer
Ga-68 PSMA AUC by SNMMI EANM
AUC: Appropriate Use CriteriaReferences: Fendler WP EJNM 2017
![Page 40: Ramathibodi Ga-68 PSMA cases - Mahidol University · PET tracers for Prostate cancer F-18 NaF F-18 FDG F-18 FCH Ga-68 PSMA Tc-99m MDP *References: PET clinics, Calabria F et.al NMB](https://reader035.vdocuments.net/reader035/viewer/2022070800/5f024eba7e708231d4039efe/html5/thumbnails/40.jpg)
ขอบคุณค่ะ
เวชศาสตร์นิวเคลียร์ รามาธิบดี