University of Groningen Exploring new molecular imaging concepts of prostate cancer Wondergem, Maurits

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University of Groningen

Exploring new molecular imaging concepts of prostate cancer

Wondergem, Maurits

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2017

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Wondergem, M. (2017). Exploring new molecular imaging concepts of prostate cancer. University of

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Intermezzo

High

18

F-DCFPyL uptake in

adrenal adenomas

Manuscript accepted for publication in Clinical Nuclear Medicine

Johannes Gerrit Karel Pepera

Sandra Srbljinb

Friso Martijn van der Zanta

Remco Johannes Jacob Knola

Maurits Wondergema,c

a_{Department of Nuclear Medicine, Noordwest Ziekenhuisgroep, Alkmaar, The}

Netherlands

b_{Department of Nuclear Medicine, Zaans Medisch Centrum, Zaandam, The Netherlands} c _{Department of Urology, University Medical Center Groningen, University of Groningen,}

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ABSTRACT

Radioisotope labelled prostate membrane specific antigen (PSMA) tracers have been proven sensitive and specific for detection of prostate cancer localizations. Uptake of those tracers in various other malignant and benign lesions have been reported recently, including faint accumulation of 68_{Ga PSMA HBED-CC in an adrenal adenoma. This report}

shows high 18_{F-DCFPyL, a promising}18_{F-labelled PSMA ligand, uptake in bilateral enlarged}

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Figure 1. 18_{F-DCFPyL PET/CT images of a 77 year-old male diagnosed with prostate carcinoma in} 2013 (cT3NxM1, Gleason 9, initial PSA 574 ng/ml). At primary staging 99m_{Tc-HDP bone scan showed} multiple bone metastases (not shown) and as a consequence Luteinizing Hormone-Releasing Hormone agonist therapy was initiated. A PSA nadir of 8,6 ng/ml was reached, after which slowly rising PSA levels were observed from March 2016. 99m_{Tc-HDP bone scan in October 2016 showed no} evidence for active bone metastases and subsequently the patient was referred for 18_{F-DCFPyL PET/} CT to localize the foci responsible for the rising PSA levels.

A mean intensity projection of the 18_{F-DCFPyL PET is shown (A).}18_{F-DCFPyL PET/CT (B,C and D) images} show focally increased uptake in the primary tumour, dorsally in the left lobe of the prostate (SUV-bw_max_{120 min p.i.} 9.12). No signs of lymph node and bone metastases were found.

Interestingly high 18_{F-DCFPyL uptake was detected in bilateral enlarged adrenals (E,F and G). For the} left and right adrenal mass respectively, SUV-bw_max_{120 min p.i.} was 18.6 and 22.9 and mean Hounsfield Units (HU) 7 and 29 on CT without intravenous contrast. The left adrenal was highly likely to be an adenoma given the HU below 10 (1). For the right adrenal other aetiologies such as adrenal myelolipoma, adrenal hyperplasia, adrenal metastasis or a lipid-rich-adrenal cyst could not be excluded since the HU exceeded 10.

PSMA tracers have been shown to be highly sensitive and specific for prostate cancer (2-5). These tracers are primarily labelled with 68_{Ga when used in clinical practice, however there is an increasing} interest in 18_{F labelled PSMA tracers as a result of favourable physical and imaging characteristics.} 18_{F-DCFPyL is a promising}18_{F labelled PSMA ligand (6, 7). A recent case report showed faint} accumulation of 68_{Ga PSMA HBED-CC in an adrenal adenoma (8), but there are no reports of adrenal} masses with high uptake of PSMA ligands.

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Figure 2. To further elucidate the nature of the adrenal masses a multiphase CT with a

non-contrast-enhanced (A), portal venous (B) and delayed phase (C) was performed.

The right adrenal mass demonstrated HU 20 on the non-contrast-enhanced CT, HU 39 on the portal venous phase and HU 25 on the late phase. The absolute washout was 74%. The left adrenal mass showed HU <10 corresponding to fat and an absolute washout of 64%. Therefore, the CT characteristics indicate that both adrenals are adenomas (1).

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REFERENCES

1. Caoili EM, Korobkin M, Francis IR, et al. Adrenal masses: Characterization with combined unenhanced and delayed enhanced CT. Radiology. 2002;222:629-633.

2. Park SW, Kim TN, Yoon JH, et al. The washout rate on the delayed CT image as a diagnostic tool for adrenal adenoma verified by patjology: a multicentre study. Int Urol Nephrol. 2012;44: 1397-1402.

3. Afshar-Oromieh A, Malcher A, Eder M, et al. PET imaging with a [68Ga]gallium-labelled PSMA ligand for the diagnosis of prostate cancer: Biodistribution in humans and first evaluation of tumour lesions. Eur J Nucl Med Mol Imaging. 2013;40:486-495.

4. Eder M, Neels O, Muller M, et al. Novel preclinical and radiopharmaceutical aspects of [68Ga] ga-PSMA-HBED-CC: A new PET tracer for imaging of prostate cancer. Pharmaceuticals (Basel). 2014;7:779-796.

5. Afshar-Oromieh A, Zechmann CM, Malcher A, et al. Comparison of PET imaging with a (68)ga-labelled PSMA ligand and (18)F-choline-based PET/CT for the diagnosis of recurrent prostate cancer. Eur J Nucl Med Mol Imaging. 2014;41:11-20.

6. Bluemel C, Krebs M, Polat B, et al. 68Ga-PSMA-PET/CT in patients with biochemical prostate cancer recurrence and negative 18F-choline-PET/CT. Clin Nucl Med. 2016;41:515-521.

7. Rowe SP, Macura KJ, Mena E, et al. PSMA-based [(18)F]DCFPyL PET/CT is superior to conventional imaging for lesion detection in patients with metastatic prostate cancer. Mol Imaging Biol. 2016;18:411-419.

8. Dietlein M, Kobe C, Kuhnert G, et al. Comparison of [(18)F]DCFPyL and [ (68)ga]ga-PSMA-HBED-CC for PSMA-PET imaging in patients with relapsed prostate cancer. Mol Imaging Biol. 2015;17:575-584.

9. Law WP, Fiumara F, Fong W, Miles KA. Gallium-68 PSMA uptake in adrenal adenoma. J Med