Review of ¹⁸F-Fluciclovine PET for Detection of Recurrent Prostate Cancer

Abstract

Fluorine 18 (18 F) fluciclovine (anti-1-amino-3-18 F-fluorocyclobutane-1-carboxylic acid [FACBC]) is a radiolabeled amino acid analog that takes advantage of the amino acid transport upregulation in several types of cancer cells. FACBC is taken up to a greater extent in prostate cancer cells than in surrounding normal tissue, providing an opportunity for its use in cases of this common cancer. In 2016, the U.S. Food and Drug Administration found the accuracy of FACBC PET to be superior to that of other molecular imaging techniques and subsequently granted approval for its use in PET of recurrent prostate cancer. As FACBC is an 18 F radiotracer, an on-site cyclotron is not required for its production. This feature enables the widespread clinical availability of this agent and, in turn, an opportunity for improved patient care. The clinical pharmacology and imaging features of FACBC are reviewed, and the role of this agent in the imaging of recurrent prostate cancer, within the context of research that supports its effectiveness, is discussed. The administration of and image acquisition facilitated by using FACBC, as compared with 18 F fluorodeoxyglucose, which is more widely used, are described. In addition, the criteria for interpreting FACBC imaging findings are outlined, with emphasis on common causes of false-positive and false-negative findings. ©

18F-fluciclovine (Axumin) PET/CT detecting occult bone metastasis

“…The most intense physiologic tracer uptake is seen in the pancreas, which decreases within 15 min after injection to a level lower than that of the liver. The liver has second most intense physiologic activity and is the most critical organ for radiation [1,6]. Axumin PET image interpretation is predominantly visual or qualitative, rather than measurement of actual SUV.…”

“…His PSA level was markedly elevated (6.1 ng/mL) from his baseline (< 0.1 ng/mL) indicating biochemical recurrence of the prostate cancer. Only < 5% of bone scans are positive for detecting bony metastasis at PSA level < 7 ng/ mL, as well as bone scans are more sensitive to detect sclerotic lesions [1]. Since our patient had radiologically occult disease with no significant abnormality on pelvic CT, our multidisciplinary team thought to proceed with Axumin PET/CT.…”

“…About 1/3 rd cases of prostate cancer develop biochemical recurrence during post-treatment surveillance. After treatment for localized prostate cancer, patients are followed up with serial PSA level to detect biochemical recurrence [1]. 18F-fluciclovine (Axumin) is a novel radiolabeled amino acid analog with higher uptake in prostate cancer cells than in the surrounding tissues.…”

“…Although 18Ffluorodeoxyglucose (18F-FDG) is a widely available workhorse tracer agent for vast majority of the cancers, it has limited role in prostate cancer imaging due to its poor sensitivity for both initial staging as well as recurrence localization. Poor sensitivity is attributed to most prostate cancers utilizing non-glucose metabolic pathway, small size of recurrent lesions, and adjacent intense urinary bladder activity [1,2]. 18F-fluciclovine (Axumin) is the only 18 F-based radiotracer that the US Food and Drug Administration (FDA) has approved for molecular imaging in patients suspected of having recurrent prostate cancer.…”

“…It has better recurrence detection rate than 11Ccholine and 18F-FDG positron emission tomography (PET); currently, it is the most sensitive approved novel agent for detection of biochemical recurrence of the prostate cancer [2]. Axumin PET is indicated in localizing recurrent disease in prostate/prostatectomy bed, pelvic or distant lymph nodal disease, and bony as well as distant/ visceral metastasis in patients with rising PSA after treatment completion [1,2]. Detecting sites of relapse and characterizing extent of tumor provide crucial information for appropriate treatment planning.…”