FLUPROSTIC : place de la TEP/TDM au Fluor-18 et de l’IRM de diffusion « corps entier » dans la détection des premières métastases osseuses du cancer de la prostate

Purpose: the occurrence of bone metastases is an important prognostic factor and a turning point in the therapeutic management of prostate cancer. Three innovative imaging studies have become increasingly important in their search: NaF PET-CT, FCH PET-CT and whole-body MRI with diffusion-weighted sequences. The main objective of this study is to compare their diagnostic performances in detecting the occurrence of bone metastatic dissemination. Method: 111 men with prostate cancer were enrolled in this prospective multi-center national study and 85 were included in the analysis. Within less than a month, they received all 3 exams. The diagnostic performances were determined from blind readings after comparison with the standard of truth established according to the monitoring data collected during a mean follow-up of 22 months. Results : 11 patients were metastatic to bone (12.9%). Regardless of the patient's initial risk level, the performances of FCH PET-CT, NaF PET-CT and whole-body MRI are equivalent at the bone level (Se 75%, 92%, 67%, p = 0.368, and Sp 99%, 95%, 96%, p = 0.05). However, on a patient-based analysis, FCH PET-CT showed better sensitivity than MRI (Se 89% vs 27%, p < 0.0001), detecting more sites affected by extra-osseous disease. This results in a greater clinical impact rate of PET-CT on therapeutic management than that of MRI. Conclusion : this study showed equivalent performances in detecting bone metastases between the 3 techniques, but higher patient-based performances of FCH PET-CT. It appears thus appropriate to grant a prominent place for FCH PET-CT, allowing, within the framework of an overall assessment of the disease extent, a reliable search of a bone metastatic extension without misunderstanding an extra-osseous extension.Objectif : l’apparition de métastases osseuses constitue un tournant dans la prise en charge thérapeutique et le pronostic du cancer de la prostate. Trois examens d’imagerie innovants occupent une place importante dans leur recherche : la TEP/TDM à la FCH, la TEP/TDM au FNa et l’IRM du corps entier avec séquences de diffusion. L’objectif principal de cette étude est de comparer leurs performances dans la détection de l’apparition des métastases osseuses. Matériel et méthode : 111 patients ont été recrutés dans cette étude prospective multi-centrique et 89 ont été retenus dans l’analyse, après avoir bénéficié dans un délai d’un mois des trois examens. Les performances diagnostiques des trois techniques ont été déterminées en confrontant les lectures en insu avec l’étalon de vérité établi d’après les données du suivi (concentrations sériques de PSA, résultats d’imagerie ou d’histologie) collectées durant une durée moyenne de 22 mois. Résultats : 12 patients présentaient des métastases osseuses (13,5%). Quel que soit le niveau de risque initial, les performances de la TEP/TDM à la FCH, de la TEP/TDM au FNa et de l’IRM étaient équivalentes au niveau du squelette (Se 75%, 92%, 67%, p = 0,368, et Sp 99%, 95%, 96%, p = 0,05). Au niveau patient cependant, la TEP/TDM à la FCH a montré une meilleure sensibilité que l’IRM (89% contre 27%, p < 0,0001), en détectant davantage de sites extra-osseux sièges d’une extension néoplasique. Cela s’est traduit par un taux d’impact clinique de la TEP/TDM sur la prise en charge thérapeutique plus important que celui de l’IRM. Conclusion : cette étude a montré des performances importantes et équivalentes des trois techniques pour la détection des métastases osseuses, mais une supériorité de la TEP/TDM à la FCH en termes de sensibilité au niveau patient, ce qui suggère une place prépondérante de cette technique dans le cadre d’un bilan global, permettant de rechercher une extension osseuse de manière fiable sans méconnaître une extension extra-osseuse

68Ga-PSMA-11 PET/CT in restaging castration-resistant nonmetastatic prostate cancer: detection rate, impact on patients’ disease management and adequacy of impact

International audienceAbstract We aimed to evaluate the impact of prostate-specific membrane antigen ligand labelled with gallium-68 (PSMA-11) PET/CT in restaging patients with castration-resistant nonmetastatic prostate cancer (PCa). Thirty patients were included. At least one malignant focus was found in 27/30 patients (90%). The PSMA-11 PET/CT positivity rate in patients whose prostate-specific antigen serum level (PSA) was greater than 2 ng/ml was 100% (20/20), significantly superior to that of patients whose PSA was less than 2 ng/ml (7/10 = 70%). Six patients (20%) were categorized as oligometastatic (≤3 metastatic foci). Based on the 17 patients for whom a standard of truth was feasible, the overall sensitivity and specificity of PSMA-11 PET/CT in detecting residual disease in castration-resistant PCa patients were 87% and 100% respectively. PSMA-11 PET/CT impacted patients’ disease management in 70% of cases, 60% of case when PSA was less than 2 ng/ml. This management was considered as adequate in 91% of patients. PSMA-11 PET/CT appeared to be effective in restaging patients with castration-resistant nonmetastatic PCa. PSMA-11 PET/CT should be considered as a replacement for bone scans under these conditions

Role of 68Ga-DOTATOC PET/CT in Insulinoma According to 3 Different Contexts: A Retrospective Study

International audienceObjective: The aim of this study was to assess the performance of 68Ga-DOTATOC PET/CT in the detection and extension of insulinomas according to 3 different contexts: sporadic benign, sporadic metastatic, and multiple endocrine neoplasia type 1 (MEN1).Patients and methods: The data of 71 adult patients who underwent 68Ga-DOTATOC PET/CT for suspected or confirmed sporadic insulinoma, suspicion of insulinoma in the context of MEN1, follow-up of metastatic insulinoma, or suspicion of recurrence of insulinoma were retrospectively analyzed. Pathological examination or strong clinical and biological findings were used as standards of truth.Results: For the assessment of a confirmed sporadic insulinoma in 17 patients, the sensitivity of SR-PET was 75%, including 2 patients for whom metastatic lesions had been revealed by SR-PET. For 35 patients with a suspicion of insulinoma, the sensitivity was 39%. In 10 patients followed up for metastatic insulinoma, the sensitivity was 100%. For 5 patients with a history of MEN1, interpretation of SR-PET was difficult, as 3 of them presented with multiple pancreatic uptake foci. The global sensitivity of SR-PET in all insulinomas excluding those with a MEN1 story was 64% (100% for metastatic insulinomas, 62% for benign insulinomas), with a specificity of 89%.Conclusions: 68Ga-DOTATOC PET/CT is a useful examination tool for the assessment of insulinomas in selected contexts, with very high performance for the detection and extension workup of metastatic insulinomas and high specificity for the detection of sporadic benign insulinomas. The examination should be completed with GLP-1 receptor PET when it is negative or in a MEN1 context

Comparison of F-sodium fluoride PET/CT, F-fluorocholine PET/CT and diffusion-weighted MRI for the detection of bone metastases in recurrent prostate cancer: a cost-effectiveness analysis in France.

BACKGROUND: The diagnostic performance of 18F-sodium fluoride positron emission tomography/computed tomography (PET/CT) (NaF), 18F-fluorocholine PET/CT (FCH) and diffusion-weighted whole-body magnetic resonance imaging (DW-MRI) in detecting bone metastases in prostate cancer (PCa) patients with first biochemical recurrence (BCR) has already been published, but their cost-effectiveness in this indication have never been compared. METHODS: We performed trial-based and model-based economic evaluations. In the trial, PCa patients with first BCR after previous definitive treatment were prospectively included. Imaging readings were performed both on-site by local specialists and centrally by experts. The economic evaluation extrapolated the diagnostic performances of the imaging techniques using a combination of a decision tree and Markov model based on the natural history of PCa. The health states were non-metastatic and metastatic BCR, non-metastatic and metastatic castration-resistant prostate cancer and death. The state-transition probabilities and utilities associated with each health state were derived from the literature. Real costs were extracted from the National Cost Study of hospital costs and the social health insurance cost schedule. RESULTS: There was no significant difference in diagnostic performance among the 3 imaging modalities in detecting bone metastases. FCH was the most cost-effective imaging modality above a threshold incremental cost-effectiveness ratio of 3000€/QALY when imaging was interpreted by local specialists and 9000€/QALY when imaging was interpreted by experts. CONCLUSIONS: FCH had a better incremental effect on QALY, independent of imaging reading and should be preferred for detecting bone metastases in patients with biochemical recurrence of prostate cancer. TRIAL REGISTRATION: NCT01501630. Registered 29 December 2011

Impact of sodium 18F-fluoride PET/CT, 18F-fluorocholine PET/CT and whole-body diffusion-weighted MRI on the management of patients with prostate cancer suspicious for metastasis: a prospective multicentre study

International audiencePurpose To compare the impact of 18F-sodium-fluoride (NaF) PET/CT, 18F-fluorocholine (FCH) PET/CT and diffusion-weighted whole-body MRI (DW-MRI) on the management of patients with prostate cancer (PCa) suspicious for distant metastasis. Methods Prostate cancer patients were prospectively included between December 2011 and August 2014 and benefited from these three whole-body imaging (WBI) modalities within 1 month in addition to the standard PCa workup. Management was prospectively decided by clinicians during two multidisciplinary meetings, before and after the whole-body imaging workup. Rates of induced changes of whole-body imaging modalities were compared by Cochran's Q test. Results One-hundred-one patients (27 at staging, 59 at first biochemical recurrence (BCR) and 15 at first episode of rising serum level of prostate-specific antigen during androgen-deprivation therapy) were included. The overall rate of management changes was 52%: 29% as a consequence of WBI, higher for FCH-PET/CT than for NaF-PET/CT or DW-MRI (p < 0.0001) and highest (41%) for FCH-PET/CT at BCR. Actual management was adequate in all patients but two. Conclusions Whole-body imaging induced a change in management in approximately a third of PCa patients suspicious for metastasis

Multiple endocrine neoplasia type 1 or 4: detection of hyperfunctioning parathyroid glands with 18F-fluorocholine PET/CT. Illustrative cases and pitfalls

18F-fluorocholine (FCH) PET/CT is now well established to detect the hyperfunctioning parathyroid glands (HFPTG) in a case of sporadic primary hyperparathyroidism (pHPT), but only limited evidence is available about the utility of FCH PET/CT to detect the HFPTG in patients with multiple endocrine neoplasia (MEN) type 1 or 4. The pHPT in this context frequently consists in a multiglandular disease with small hyperplastic glands rather than adenomas, which is challenging for imaging modalities. The data of patients with MEN1 or MEN4 after parathyroidectomy referred to FCH PET/CT for presurgical localization of HFPTG were retrospectively reviewed, including follow-up after parathyroidectomy, in search for diagnostic performance and for potential pitfalls. In the present cohort, 16 patients referred to FCH PET/CT as part of their initial pHPT work-up were subsequently operated, 44 abnormal parathyroid glands (PT) were resected, of which 32 (73%) had been detected on FCH PET/CT and 2 considered as equivocal foci. Nine patients referred to FCH PET/CT for recurrent pHPT who were subsequently operated, 14 abnormal PT were resected, all had been detected on FCH PET/CT. FCH PET/CT permitted a unilateral approach for PTx in 4 of them. In one patient with MEN4 and pHPT, the HFPTG could not be visualized on FCH PET/CT but was localized by ultrasonography. Several causes of false positive or false negative results, incidental finding and pitfalls are listed and discussed. FCH PET/CT has a positive benefit/risk ratio in the detection of HFPTG in case of MEN1 (the data in MEN4 being currently very limited) with the most effective detection rate of current imaging modalities for HFPTG, few pitfalls, and an adequate impact on patient management compared to sesta MIBI SPECT and ultrasonography