ACR–ACNM Practice Parameter for the Performance of Fluorine-18 Fluciclovine-PET/CT for Recurrent Prostate Cancer

Abstract

The American College of Radiology (ACR) and American College of Nuclear Medicine (ACNM) collaborated to develop a clinical practice document for the performance of fluciclovine positron-emission tomography (PET) / computed tomography (CT) in the evaluation of patients with suspected prostate cancer recurrence based on the elevation of prostate-specific antigen (PSA) level (biochemical recurrence) after prior therapy. Prostate cancer is the third leading cause of cancer death in the United States. Up to 50% of patients diagnosed with prostate cancer will develop biochemical failure after initial therapy. The differentiation of local from extraprostatic recurrence plays a critical role in patient management. The use of functional imaging targeting features of cancer metabolism has proven highly useful in this regard. Amino acid transport is upregulated in prostate cancer. Fluciclovine (anti-1-amino-3-F-18-fluorocyclobutane-1-carboxylic acid, FACBC, Axumin™) is an artificial amino acid PET tracer which demonstrates utility in the diagnosis of recurrent prostate cancer with significant added value to conventional imaging.

Best Practices for 18F-Fluciclovine PET/CT Imaging of Recurrent Prostate Cancer: A Guide for Technologists

“…In clinical experience, patients who voided just before 18 F-fluciclovine injection had higher early 18 F-fluciclovine bladder excretion compared with those who did not void. Therefore, patients should be advised not to void immediately before injection and imaging (9,10). For centers that perform the PET/CT scan with an oral contrast medium, it is suggested that the patients refrain from voiding for 1 h after administration of the contrast medium until after the 18 F-fluciclovine has been injected and the imaging completed (9).…”

“…Therefore, patients should be advised not to void immediately before injection and imaging (9,10). For centers that perform the PET/CT scan with an oral contrast medium, it is suggested that the patients refrain from voiding for 1 h after administration of the contrast medium until after the 18 F-fluciclovine has been injected and the imaging completed (9). For patients with a Foley catheter, no specific intervention is required.…”

“…The remaining dose within the syringe is assayed to determine residual activity. The assayed, residual, and net administered dose, as well as the injected site, should be recorded (9). Subsequently, the net administered dose is used for the SUV calculation.…”

“…However, the density of the contrast medium may result in an attenuation correction artifact (13). If contrast medium is used, the CT images should be obtained after the PET acquisition to minimize the diuretic effect of the medium on 18 F-fluciclovine (9). The use of a high-quality CT scan as an attenuation-correction CT scan is not mandatory but is preferable for better characterization of small suggestive structures.…”

“…According to the American College of Radiology technical standards, quality control for 18 F-fluciclovine PET is no different from that for other types of PET imaging, such as 18 F-FDG PET/CT (9).…”