Pattern of failure in prostate cancer previously treated with radical prostatectomy and post-operative radiotherapy: a secondary analysis of two prospective studies using novel molecular imaging techniques

Lindsay S Rowe, Stephanie Harmon, Adam Horn, Uma Shankavaram, Soumyajit Roy, Holly Ning, Liza Lindenberg, Esther Mena, Deborah E Citrin, Peter Choyke, Baris Turkbey, Lindsay S Rowe, Stephanie Harmon, Adam Horn, Uma Shankavaram, Soumyajit Roy, Holly Ning, Liza Lindenberg, Esther Mena, Deborah E Citrin, Peter Choyke, Baris Turkbey

Abstract

Background: Prostate Membrane Specific Antigen (PSMA) positron emission tomography (PET) and multiparametric MRI (mpMRI) have shown high accuracy in identifying recurrent lesions after definitive treatment in prostate cancer (PCa). In this study, we aimed to outline patterns of failure in a group of post-prostatectomy patients who received adjuvant or salvage radiation therapy (PORT) and subsequently experienced biochemical recurrence, using 18F-PSMA PET/CT and mpMRI.

Methods: PCa patients with biochemical failure post-prostatectomy, and no evident site of recurrence on conventional imaging, were enrolled on two prospective trials of first and second generation 18F-PSMA PET agents (18F-DCFBC and 18F-DCFPyL) in combination with MRI between October 2014 and December 2018. The primary aim of our study is to characterize these lesions with respect to their location relative to previous PORT field and received dose.

Results: A total of 34 participants underwent 18F-PSMA PET imaging for biochemical recurrence after radical prostatectomy and PORT, with 32/34 found to have 18F-PSMA avid lesions. On 18F-PSMA, 17/32 patients (53.1%) had metastatic disease, 8/32 (25.0%) patients had locoregional recurrences, and 7/32 (21.9%) had local failure in the prostate fossa. On further exploration, we noted 6/7 (86%) of prostate fossa recurrences were in-field and were encompassed by 100% isodose lines, receiving 64.8-72 Gy. One patient had marginal failure encompassed by the 49 Gy isodose.

Conclusions: 18F-PSMA PET imaging demonstrates promise in identifying occult PCa recurrence after PORT. Although distant recurrence was the predominant pattern of failure, in-field recurrence was noted in approximately 1/5th of patients. This should be considered in tailoring radiotherapy practice after prostatectomy. Trial registration www.clinicaltrials.gov , NCT02190279 and NCT03181867. Registered July 12, 2014, https://ichgcp.net/clinical-trials-registry/NCT02190279 and June 8 2017, https://ichgcp.net/clinical-trials-registry/NCT03181867 .

Keywords: Biochemical recurrence; F-18; PET/CT; Prostate cancer; Prostate-specific membrane antigen (PSMA); Prostatectomy; Radiation therapy.

Conflict of interest statement

BT reports non-financial support from Philips, non-financial support from NVIDIA, other from InVivo Coorperation, outside the submitted work. SR reports grants from Abbvie-Canadian Association of Radiation Oncology Uro-oncologic award (ACURA), Grants from BC Cancer Agency—Radiotherapy Education Process Fund, outside the submitted work. The authors declare that they have no other conflicts of interest.

Figures

Fig. 1
Fig. 1
58-year-old male with a serum PSA of 3.09 ng/ml after radical prostatectomy and salvage radiotherapy with ADT. 18F-PSMA-PET image overlaid with radiation treatment dosimetry. The patient received a prescribed dose of 70.2 Gy
Fig. 2
Fig. 2
Distribution of 18F-PSMA PET/CT avid lesions in the abdomen and pelvis (pulmonary and supraclavicular metastases not shown) for the 32 patients included in the analysis
Fig. 3
Fig. 3
57-year-old male with a serum PSA of 3.14 ng/ml after radical prostatectomy and salvage radiation and ADT. 18F-DCFPYL PET/CT shows focal radiotracer uptake within the left iliac chain normal size lymph nodes (arrows)
Fig. 4
Fig. 4
66-year-old male with serum PSA of 4.83 ng/ml after radical prostatectomy and salvage radiation therapy. 18F-DCFPYL PET/CT shows focal radiotracer uptake within bilateral pelvic lymph nodes (black arrows) (a) and in a normal sized supraclavicular lymph node (red arrows) (a–c)
Fig. 5
Fig. 5
Axial MRI and 18F-PSMA PET/CT images of each of the seven patients with isolated local recurrence. White arrows point to areas of interest

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