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Prostate Cancer Imaging and Therapy PROSTATE CANCER IMAGING AND THERAPY A TECHNOLOGIST’S GUIDE Produced with the kind support of Chapters marked with this symbol are made available to you as webinar on the EANM eLearning platform: elearning.eanm.org TABLE OF CONTENTS Foreword 4 Pedro Fragoso Costa Introduction 6 Luca Camoni Chapter 1 Anatomy, physiology and pathology of the prostate 9 Lucia Zanoni, Cristina Nanni and Stefano Fanti Chapter 2 Clinical radiopharmaceuticals for prostate cancer 21 Martin Behe Chapter 3 Conventional nuclear medicine in prostate cancer imaging 29 Wolfgang Römer Chapter 4 PET/CT procedures with fluorine-18 41 radiopharmaceuticals in prostate cancer* Daniel Tempesta and David Gilmore Chapter 5 Prostate cancer PET-CT imaging beyond F-18 tracers 51 Giorgio Testanera and Giovanna Pepe Chapter 6 PET/CT-guided radiotherapy planning in prostate cancer 73 Yat Man Tsang and Michelle Leech Chapter 7 Theranostics in Prostate Cancer 83 Sarah M. Schwarzenböck, Bernd Joachim Krause and Jens Kurth Chapter 8 Prostate cancer radionuclide therapy based on alpha emitters 95 Mark Konijnenberg and Domenico Albano Chapter 9 The management of a prostate cancer patient 105 MarieClaire Attard and Rexhep Durmo Chapter 10 Future perspectives and preclinical studies in prostate cancer 123 Laura Evangelista and Federico Caobelli *Articles were written with the kind support of and in cooperation with the EANM TECHNOLGIST’S GUIDE 3 PROSTATE CANCER IMAGING AND THERAPY FOREWORD Foreword Individualised medicine and tailored treatment solutions are nowadays unimaginable without diagnostic imaging. The development and implementation of disease-specific tracers within nuclear medicine has impacted on patient clinical management and positively affected the lives of thousands of patients all over the globe. Nuclear medicine technologists are spe- radiopharmacists and dosimetrists whose cialised professionals who perform or are coordinated effort has culminated in this involved in a number of procedures, in- guide. Such an ongoing joint effort is the cluding radiopharmaceutical labelling, pa- reason behind the acknowledged wide tient management, image reconstruction readership for past editions of A Technolo- and radiation safety. gist’s Guide (TG) and the extremely positive The multidisciplinary effort in nuclear response that EANM receives every year medicine to discover new molecules with concerning this publication. a significant clinical impact is well known This year’s edition of the TG celebrates a through the recent research and devel- return to clinical applications, being to- opments with respect to diagnostic and tally focussed on one pathology in which therapeutic radiopharmaceuticals for use nuclear medicine is deeply involved. The in prostate cancer. motivation for the content design of this As a reference scientific body in Europe, the TG was the desire to explore the multi- European Association of Nuclear Medicine disciplinary approach to prostate cancer, (EANM), and its Technologist Committee from preclinical studies with animal mod- (EANMTC), has had the privilege of gather- els through to established diagnostic and ing top quality clinical scientists, technolo- therapeutic methodologies. The guide gists, physicians, physicists, radiochemists, accordingly provides a complete overview 4 EANM TECHNOLGIST’S GUIDE PROSTATE CANCER IMAGING AND THERAPY FOREWORD of the nuclear medicine vision regarding of this book could not have been realised. prostate cancer, from anatomy to clinical From overseas my gratitude extends to the tracers, with consideration of both con- Society of Nuclear Medicine and Molecular ventional nuclear medicine and PET/CT Imaging Technologist Section (SNMMI-TS) and both fluorine-18 and non-fluorine-18 and I would also like to thank the European tracers. The role of nuclear medicine with Society of Radiotherapy & Oncology (ES- respect to external radiotherapy is also TRO) Radiation Therapist (RTT) Committee discussed in this TG, as are a range of ther- for their valuable contribution. apeutic and theranostic applications. Like- Lastly, I am very much indebted to the wise, patient-focussed practice and trans- EANM-TC editorial group, to Rick Mills for lational medicine chapters are presented. copyediting assistance and to the EANM I would like to express my gratitude for the Board and Executive Office for their con- collective effort of all authors who partici- tinuous support on one of the most signif- pated in this publication. Special thanks are icant and well-received projects to origi- due to the EANM Technologist, Oncology, nate from our committee. Radiopharmacy, Dosimetry and Transla- tional Molecular Imaging & Therapy Com- mittees involved in this venture, without Pedro Fragoso Costa whom the truly multidisciplinary nature Chair of the EANM Technologist Committee EANM TECHNOLGIST’S GUIDE 5 PROSTATE CANCER IMAGING AND THERAPY INTRODUCTION Introduction Prostate cancer is the second most common cancer in men worldwide. Due to increasing life expectancy and the introduction of more sensitive diagnostic screening techniques, prostate cancer is being diagnosed more frequently, with rapidly increasing incidence and prevalence. It has a wide spectrum of biological behaviour, ranging from indolent low-risk disease to highly aggressive castration-resistant prostate cancer. Nuclear medicine imaging plays a key role and hybrid SPECT/CT. The following two in this heterogeneous disease as it can chapters provide an overview on pro- answer key clinical questions at various tocols and the diagnostic value of PET/ phases of the disease, the imaging being CT imaging using fluorine-18 and other tailored to each phase. Nuclear medicine non-fluorine-18 radioisotopes labelled has demonstrated efficacy for cancer de- with different molecules. PET/CT is a use- tection, with an increasing number of po- ful tool for guided radiotherapy planning; tential targets for imaging and treatment. consequently the sixth chapter describes The first chapter of this book describes the acquisition and reconstruction proto- the prostate’s anatomy, physiology and col for the purpose of radiotherapy. One of pathology. The radiopharmaceuticals that the most recent developments in nuclear allow study or treatment of prostate cancer medicine is theranostics: the seventh chap- are discussed in the subsequent chapter. ter reviews the state of the art, describing Conventional nuclear medicine represents the use of theranostic pairs and quantita- a cost-effective resource in the manage- tive analysis of tissue and tumour uptake ment of prostatic disease, and the third in optimisation of patient treatment. The chapter documents the specific imaging eighth chapter broadens the vision of the procedures for diagnostic planar imaging field of therapy, adding treatment based 6 EANM TECHNOLGIST’S GUIDE PROSTATE CANCER IMAGING AND THERAPY INTRODUCTION on alpha-emitting radionuclides. Nuclear fields in preclinical cancer drug research medicine technologists play an important and development. part in the multi-professional manage- We hope that this overview of the state ment of the prostate cancer patient. In of the art of nuclear medicine imaging and addition to being directly involved in ther- therapy in prostate cancer will provide a apy through the performance of various valuable resource for all technologists and roles, they are responsible for other tasks clinical staff involved in this field. such as patient preparation and imaging The EANM Technologist Committee processing. The ninth chapter describes would like to thank all the authors who the clinical pathway of the patient in order have kindly offered their time and exper- to improve understanding of the technol- tise, which have been fundamental to the ogist’s tasks. creation of this book. The recent advances in prostate cancer specific tracers were significantly support- ed by the advent of translational medicine. Luca Camoni With this in mind, the final chapter explains on behalf of the editors how molecular and non-invasive preclin- ical imaging become rapidly emerging EANM TECHNOLGIST’S GUIDE 7 PROSTATE CANCER IMAGING AND THERAPY ANATOMY, PHYSIOLOGY AND PATHOLOGY OF THE PROSTATE by Lucia Zanoni, Cristina Nanni and Stefano Fanti 1 CHAPTER 1 INTRODUCTION PATHOLOGY OF THE PROSTATE THE OF PATHOLOGY AND PHYSIOLOGY ANATOMY, The prostate is a glandular and muscular structure positioned immediately below the neck of the bladder and around the commencement of the urethra. It is located within the pelvic cavity, below the inferior margin of the symphysis pubis and above the triangular ligament, anterior to the rectum. Its base is below the neck of the bladder and is directed upwards, whereas the apex touches the ligament and is directed downwards. Its posterior surface is close to the second part of the rectum, whereas its anterior surface is connected to the pubis by puboprostatic ligaments. The lateral surfaces are in contact with the levator ani muscles[1]. The prostate consists of two lateral lobes, systemic steroid hormone signals, local equal in dimension, and a third middle paracrine signalling pathways and cell lobe, which lies in the central posterior autonomous factors. The prostate is an region. It is surrounded by a thin, fibrous exocrine gland whose role is part of the capsule separated by a plexus of veins male reproductive function in mammals. from the rectovesical fascia. Immediately The mouse has emerged as the most im- below the capsule, there is muscular tis- portant model system for investigation of sue, which
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