A Prospective Comparison of F-18-Sodium Fluoride PET/CT and PSMA-Targeted F-18-DCFBC PET/CT in Metastatic Prostate Cancer

The purpose of this study was to compare the diagnostic performance of F-18-DCFBC PET/CT, a first-generation F-18-labeled prostate-specific membrane antigen (PSMA)-targeted agent, and F-18-NaF PET/CT, a sensitive marker of osteoblastic activity, in a prospective cohort of patients with metastatic prostate cancer. Methods: Twenty-eight prostate cancer patients with metastatic disease on conventional imaging prospectively received up to 4 PET/CT scans. All patients completed baseline F-18-DCFBC PET/CT and F-18-NaF PET/CT scans, and 23 patients completed follow-up imaging, with a median follow-up interval of 5.7 mo (range, 4.2-12.6 mo). Lesion detection was compared across the 2 PET/CT agents at each time point. Detection and SUV characteristics of each PET/CT agent were compared with serum prostate-specific antigen (PSA) levels and treatment status at the time of baseline imaging using nonparametric statistical testing (Spearman correlation, Wilcoxon rank). Results: Twenty-six patients had metastatic disease detected on F-18-NaF or F-18-DCFBC at baseline, and 2 patients were negative on both scans. Three patients demonstrated soft tissue-only disease. Of 241 lesions detected at baseline, 56 were soft-tissue lesions identified by F-18-DCFBC only and 185 bone lesions detected on F-18-NaF or (FDCFBC)-F-18. F-18-NaF detected significantly more bone lesions than (FDCFBC)-F-18 (P< 0.001). Correlation of PSA with patient-level SUV metrics was strong in F-18-DCFBC (< 0.5, P< 0.01) and poor in F-18-NaF (rho< 0.3, P. 0.1). When PSA levels were combined with treatment status, patients with below-median levels of PSA rho< 2 ng/mL) on androgen deprivation therapy (n = 11) demonstrated more lesions on F-18-NaF than F-18-DCFBC (P = 0.02). In PSA greater than 2 ng/mL, patients on androgen deprivation therapy (n 5 8) showed equal to or more lesions on F-18-DCFBC than on F-18-NaF. Conclusion: The utility of PSMA-targeting imaging in metastatic prostate cancer appears to depend on patient disease course and treatment status. Compared with F-18-NaF PET/CT, F-18-DCFBC PET/CT detected significantly fewer bone lesions in the setting of early or metastatic castrate-sensitive disease on treatment. However, in advanced metastatic castrate-resistant prostate cancer, F-18-DCFBC PET/CT shows good concordance with NaF PET/CT.

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