New horizons in prostate cancer imaging

Multiparametric Magnetic Resonance Imaging in Evaluation of Clinically Significant Prostate Cancer

Aim  In this prospective study, we evaluate the role of multiparametric magnetic resonance imaging (mp-MRI) in the assessment of clinically significant prostate cancer at 1.5 T without endorectal coil (ERC).

Materials and Methods  Forty-five men with clinical suspicion of prostate cancer (prostate-specific antigen [PSA] level > 4 ng/mL, hard prostate on digital rectal examination, and suspicious area at transrectal ultrasound [TRUS]) were evaluated using the mp-MRI protocol over a period of 24 months. All cases were interpreted using the Prostate Imaging Reporting and Data System (PI-RADS) version 2 guidelines and correlated with histopathology.

Statistical Analysis Used  A chi-squared test was used for analysis of nominal/categorical variables and receiver operating characteristic (ROC) curve and one-way analysis of variance (ANOVA) test for continuous variables.

Results  The mean age was 67 years and the mean PSA was 38.2 ng/mL. Eighty percent had prostate cancer and 20% were benign (11% benign prostatic hyperplasia [BPH] and 9% chronic prostatitis). Eighty-six percent of all malignancies were in the peripheral zone. The PI-RADS score for T2-weighted (T2W) imaging showed good sensitivity (81%) but low specificity (67%). The PI-RADS score for diffusion weighted imaging (DWI) with sensitivity of 92% and specificity of 78% had a better accuracy overall than T2W imaging alone. The mean apparent diffusion coefficient (ADC) value (×10 ^–6 mm ² /s) was 732 ± 160 in prostate cancer, 1,009 ± 161 in chronic prostatitis, 1,142 ± 82 in BPH, and 663 in a single case of granulomatous prostatitis. Low ADC values (<936) have shown good correlation (area under curve [AUC]: 0.87) with the presence of cancer foci. Inverse correlation was observed between Gleason scores and ADC values. Dynamic contrast-enhanced (DCE) imaging has shown 100% sensitivity/negative predictive value (NPV), but moderate specificity (67%) in predicting malignancy. The final PI-RADS score had 100% sensitivity and NPV with good overall positive predictive value (PPV) of 95%.

Conclusions  T2W imaging and DWI remain the mainstays in diagnosis of prostate cancer with mp-MRI. DCE-MRI can be a problem-solving tool in case of equivocal findings. Because assessment with mp-MRI can be subjective, use of the newly developed PI-RADS version 2 scoring system is helpful in accurate interpretation.

Prostate MRI: practical guidelines for interpreting and reporting according to PI-RADS version 2.1

The increasing precision of multiparametric magnetic resonance imaging of the prostate, together with greater experience and standardization in its interpretation, has given this technique an important role in the management of prostate cancer, the most prevalent non-cutaneous cancer in men. This article reviews the concepts in PI-RADS version 2.1 for estimating the probability and zonal location of significant tumors of the prostate, using a practical approach that includes current considerations about the prerequisites for carrying out the test and recommendations for interpreting the findings. It emphasizes benign findings that can lead to confusion and the criteria for evaluating the probability of local spread, which must be included in the structured report.

A non-randomized prospective study on the diagnostic performance of perineal prostatic biopsy, directed via diffusion nuclear resonance, in patients with suspected prostate cancer and previous negative transrectal prostate biopsy

BACKGROUND

A definition of the best strategy is necessary to optimize the follow-up of patients with previous negative transrectal guided ultrasound biopsy (TRUS-GB) and the persistence of raised prostate-specific antigen (PSA).The purpose of this study was to evaluate the prostate cancer (PCa) diagnostic rate of targeted transperineal ultrasound guided biopsy (TPUS-GB) with cognitive multiparametric magnetic resonance imaging (mpMRI) registration with concurrent systematic biopsy in patients with previous negative systematic TRUS-GB and persistently elevated PSA levels.

MATERIALS AND METHODS

In this prospective study conducted at the University Infanta Sofia Hospital from April 2016 to November 2017, patients with one previous negative systematic TRUS-GB and persistently high PSA levels were referred for mpMRI prostate scans. All patients underwent systematic TPUS-GB and those patients with suspicious findings on mpMRI scans, Pirads 3 and 4-5, underwent a subsequent cognitive guidance mpMRI-TPUS-GB.

RESULTS

In total, 71 patients were included in this study. Suspicious findings on mpMRI scans prior to TPUS-GB were found in 50 patients (70.4%). 16 patients were diagnosed with prostate cancer (22.5%), of whom 14 (87.5%) had a mpMRI scan with Pirads 3 or Pirads 4-5. Patients with Pirads 3, 4 or 5 showed negative results in almost all cores taken by concurrent systematic TPUS-GB.

CONCLUSIONS

Cognitive mpMRI-TPUS fusion biopsy is a useful tool to diagnose PCa in patients with previous negative prostate biopsy. The samples obtained from the suspicious areas in the mpMRI detect more cases of intermediate and high risk PCa compared to the samples obtained at random or from non-suspicious areas.

Modern imaging and image-guided treatments of the prostate gland: MR and ablation for cancer and prostatic artery embolization for benign prostatic hyperplasia

Multiparametric MRI (mpMRI) has proven to be an essential tool for diagnosis, post-treatment follow-up, aggressiveness assessment, and active surveillance of prostate cancer. Currently, this imaging technique is part of the daily practice in many oncological centres. This manuscript aims to review the use of mpMRI in the set of prostatic diseases, either malignant or benign: mpMRI to detect and stage prostate cancer is discussed, as well as its use for active surveillance. Image-guided ablation techniques for prostate cancer are also reviewed. The need to establish minimum acceptable technical parameters for prostate mpMRI, standardize reports, uniform terminology for describing imaging findings, and develop assessment categories that differentiate levels of suspicion for clinically significant prostate cancer led to the development of the Prostate Imaging Reporting and Data System that is reviewed. Special focus will also be given on the most up-to-date evidence of prostatic artery embolization (PAE) for symptomatic benign prostatic hyperplasia (BPH). Management of patients with BPH, technical aspects of PAE, expected outcomes and level of evidence are reviewed with the most recent literature. PAE is a challenging technique that requires dedicated anatomical knowledge and comprehensive embolization skills. PAE has been shown to be an effective minimally-invasive treatment option for symptomatic BPH patients, that can be viewed between medical therapy and surgery. PAE may be a good option for symptomatic BPH patients that do not want to be operated and can obviate the need for prostatic surgery in up to 80% of treated patients.

Image Guided Planning for Prostate Carcinomas With Incorporation of Anti-3-[18F]FACBC (Fluciclovine) Positron Emission Tomography: Workflow and Initial Findings From a Randomized Trial

PURPOSE

(18)F-Fluciclovine (anti-1-amino-3-[(18)F]fluorocyclobutane-1-carboxylic acid) is a novel positron emission tomography (PET)/computed tomography (CT) radiotracer that has demonstrated utility for detection of prostate cancer. Our goal is to report the initial results from a randomized controlled trial of the integration of (18)F-fluciclovine PET-CT into treatment planning for defining prostate bed and lymph node target volumes.

METHODS AND MATERIALS

We report our initial findings from a cohort of 41 patients, of the first enrolled on a randomized controlled trial, who were randomized to the (18)F-fluciclovine arm. All patients underwent (18)F-fluciclovine PET-CT for the detection of metabolic abnormalities and high-resolution CT for treatment planning. The 2 datasets were registered first by use of a rigid registration. If soft tissue displacement was observable, the rigid registration was improved with a deformable registration. Each (18)F-fluciclovine abnormality was segmented as a percentage of the maximum standard uptake value (SUV) within a small region of interest around the lesion. The percentage best describing the SUV falloff was integrated in planning by expanding standard target volumes with the PET abnormality.

RESULTS

In 21 of 55 abnormalities, a deformable registration was needed to map the (18)F-fluciclovine activity into the simulation CT. The most selected percentage was 50% of maximum SUV, although values ranging from 15% to 70% were used for specific patients, illustrating the need for a per-patient selection of a threshold SUV value. The inclusion of (18)F-fluciclovine changed the planning volumes for 46 abnormalities (83%) of the total 55, with 28 (51%) located in the lymph nodes, 11 (20%) in the prostate bed, 10 (18%) in the prostate, and 6 (11%) in the seminal vesicles. Only 9 PET abnormalities were fully contained in the standard target volumes based on the CT-based segmentations and did not necessitate expansion.

CONCLUSIONS

The use of (18)F-fluciclovine in postprostatectomy radiation therapy planning was feasible and led to augmentation of the target volumes in the majority (30 of 41) of the patients studied.

Pretargeted immunoPET of prostate cancer with an anti-TROP-2 x anti-HSG bispecific antibody in mice with PC3 xenografts

PURPOSE

Pretargeting with bispecific antibodies and radiolabeled hapten-peptides could be used to specifically target tumors with high target-to-background ratios. TF12 is a trivalent bispecific antibody that consists of two anti-TROP-2 Fab fragments and one anti-HSG (histamine-succinyl-glycine) Fab fragment. The TROP-2 antigen is expressed in many epithelial cancers, including prostate cancer (PC), and therefore, this bispecific antibody can be used for pretargeting of PC. In this study, the potential for pretargeted radioimmunoPET with TF12 and the (68)Ga-labeled di-HSG peptide IMP288 in mice with human PC xenografts was investigated using 2-deoxy-2-[(18)F]fluoro-D-glucose ([(18)F]FDG) as a reference.

PROCEDURES

The potential of pretargeted immunoPET with TF12 and the (68)Ga-labeled di-HSG hapten-peptide, IMP288, was studied in mice with subcutaneous PC3 tumors using [(18)F]FDG as a reference. Furthermore, the use of this pretargeting system for imaging PC lesions was evaluated in mice with intraperitoneally growing tumors with [(18)F]FDG as a reference.

RESULTS

[(68)Ga]lMP288 showed rapid accumulation in the TF12 pretargeted subcutaneous tumor (7.2 ± 1.1 % ID/g) with low uptake in the kidneys (1.8 ± 0.5 % ID/g) and high tumor-to-blood ratios (17.4 ± 11.2) at 1 h p.i. Accumulation of [(18)F]FDG in the s.c. tumors was significantly lower (3.4 ± 0.9 % ID/g, P = 0.008), with lower tumor-to-blood ratios (3.0 ± 1.9, P = 0.011). ImmunoPET/CT images clearly visualized both subcutaneous and intraperitoneal tumors as small as 5 mm(3) with low blood levels and kidney uptake as early as 1 h p.i.

CONCLUSION

Pretargeted immunoPET with TF12 in combination with a (68)Ga-labeled hapten-peptide is an efficient system for rapid, sensitive, and specific imaging of prostate cancer.

Clinical significance of incidental FDG uptake in the prostate gland detected by PET/CT

The value of FDG-positron emission tomography/computed tomography (PET/CT) for detecting prostate cancer is unknown. We aimed to investigate the clinical value of incidental prostate FDG uptake on PET/CT scans. We reviewed 6128 male patients who underwent FDG-PET/CT scans and selected cases that reported hypermetabolic lesion in the prostate. The patients who have prior history of prostate carcinoma or prostate surgery were excluded from the study. We have analyzed the correlation between PET/CT findings and serum prostate-specific antigen (PSA) levels, imaging (USG), urological examinations and biopsy. Incidental 18F-FDG uptake of the prostate gland was observed in 79 patients (1.3%). While sixteen of them were excluded due to inadequate clinical data, the remaining 63 patients were included for further analysis. The patients were divided into two groups; 8 patients (12.7%) in the malignant group and 55 patients (87.3%) in the benign group. The SUVmax values were not significantly different between the two groups. In 6 (75%) patients with prostate cancer, FDG uptake was observed focally in the peripheral zone of the prostate glands. There was no significant correlation between the SUVmax and the PSA levels. Incidental 18F-FDG uptake in the prostate gland is a rare condition, but a substantial portion of it is associated with the cancer. Benign and malignant lesions of the prostate gland in FDG-PET/CT imaging could not be reliably distinguished. The peripheral focally FDG uptake of prostate glands should be further examined with the clinical and labaratory evaluations.

Interpretation and reporting multiparametric prostate MRI: a primer for residents and novices

Multiparametric MRI has developed as a tool for prostate cancer lesion detection, characterization, staging, surveillance, and imaging of local recurrence. Given the disease frequency and the growing importance of imaging, as reliance on PSA declines, radiologists involved in prostate MRI imaging must become proficient with the fundamentals of multiparametric prostate MRI (T2WI, DWI, DCE-MRI, and MR spectroscopy). Interpretation and reporting must yield accuracy, consistency, and add value to clinical care. This review provides a primer to novices and trainees learning about multiparametric prostate MRI. MRI technique is presented along with the use of particular MRI sequences. Relevant prostate anatomy is outlined and imaging features of prostate cancer with staging are discussed. Finally structured reporting is introduced, and some limitations of prostate MRI are discussed.

Preclinical Evaluation of a Tailor-Made DOTA-Conjugated PSMA Inhibitor with Optimized Linker Moiety for Imaging and Endoradiotherapy of Prostate Cancer

Despite many advances in the past years, the treatment of metastatic prostate cancer still remains challenging. In recent years, prostate-specific membrane antigen (PSMA) inhibitors were intensively studied to develop low-molecular-weight ligands for imaging prostate cancer lesions by PET or SPECT. However, the endoradiotherapeutic use of these compounds requires optimization with regard to the radionuclide-chelating agent and the linker moiety between chelator and pharmacophore, which influence the overall pharmacokinetic properties of the resulting radioligand. In an effort to realize both detection and optimal treatment of prostate cancer, a tailor-made novel naphthyl-containing DOTA-conjugated PSMA inhibitor has been developed.

METHODS

The peptidomimetic structure was synthesized by solid-phase peptide chemistry and characterized using reversed-phase high-performance liquid chromatography and matrix-assisted laser desorption/ionization mass spectrometry. Subsequent (67/68)Ga and (177)Lu labeling resulted in radiochemical yields of greater than 97% or greater than 99%, respectively. Competitive binding and internalization experiments were performed using the PSMA-positive LNCaP cell line. The in vivo biodistribution and dynamic small-animal PET imaging studies were investigated in BALB/c nu/nu mice bearing LNCaP xenografts.

RESULTS

The chemically modified PSMA inhibitor PSMA-617 demonstrated high radiolytic stability for at least 72 h. A high inhibition potency (equilibrium dissociation constant [K(i)] = 2.34 ± 2.94 nM on LNCaP; K(i) = 0.37 ± 0.21 nM enzymatically determined) and highly efficient internalization into LNCaP cells were demonstrated. The small-animal PET measurements showed high tumor-to-background contrasts as early as 1 h after injection. Organ distribution revealed specific uptake in LNCaP tumors and in the kidneys 1 h after injection. With regard to therapeutic use, the compound exhibited a rapid clearance from the kidneys from 113.3 ± 24.4 at 1 h to 2.13 ± 1.36 percentage injected dose per gram at 24 h. The favorable pharmacokinetics of the molecule led to tumor-to-background ratios of 1,058 (tumor to blood) and 529 (tumor to muscle), respectively, 24 h after injection.

CONCLUSION

The tailor-made DOTA-conjugated PSMA inhibitor PSMA-617 presented here is sustainably refined and advanced with respect to its tumor-targeting and pharmacokinetic properties by systematic chemical modification of the linker region. Therefore, this radiotracer is suitable for a first-in-human theranostic application and may help to improve the clinical management of prostate cancer in the future.

Pretargeted dual-modality immuno-SPECT and near-infrared fluorescence imaging for image-guided surgery of prostate cancer

Radical removal of malignant lesions may be improved using tumor-targeted dual-modality probes that contain both a radiotracer and a fluorescent label to allow for enhanced intraoperative delineation of tumor resection margins. Because pretargeting strategies yield high signal-to-background ratios, we evaluated the feasibility of a pretargeting strategy for intraoperative imaging in prostate cancer using an anti-TROP-2 x anti-HSG bispecific antibody (TF12) in conjunction with the dual-labeled diHSG peptide (RDC018) equipped with both a DOTA chelate for radiolabeling purposes and a fluorophore (IRdye800CW) to allow near-infrared optical imaging. Nude mice implanted s.c. with TROP-2-expressing PC3 human prostate tumor cells or with PC3 metastases in the scapular and suprarenal region were injected i.v. with 1 mg of TF12 and, after 16 hours of tumor accumulation and blood clearance, were subsequently injected with 10 MBq, 0.2 nmol/mouse of either (111)In-RDC018 or (111)In-IMP288 as a control. Two hours after injection, both microSPECT/CT and fluorescence images were acquired, both before and after resection of the tumor nodules. After image acquisition, the biodistribution of (111)In-RDC018 and (111)In-IMP288 was determined and tumors were analyzed immunohistochemically. The biodistribution of the dual-label RDC018 showed specific accumulation in the TROP-2-expressing PC3 tumors (12.4 ± 3.7% ID/g at 2 hours postinjection), comparable with (111)In-IMP288 (9.1 ± 2.8% ID/g at 2 hours postinjection). MicroSPECT/CT and near-infrared fluorescence (NIRF) imaging confirmed this TROP-2-specific uptake of the dual-label (111)In-RDC018 in both the s.c. and metastatic growing tumor model. In addition, PC3 metastases could be visualized preoperatively with SPECT/CT and could subsequently be resected by image-guided surgery using intraoperative NIRF imaging, showing the preclinical feasibility of pretargeted dual-modality imaging approach in prostate cancer.

Diagnostic role of fluorodeoxyglucose positron emission tomography-computed tomography in prostate cancer

The role of fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography (PET)-computed tomography (CT) in prostate cancer remains controversial due to a limited number of previous clinical investigations. The aim of the present retrospective study was to assess the diagnostic value of FDG PET-CT in prostate cancer, with an emphasis on the detection of metastatic disease. Twenty-five relevant cases of patients with newly diagnosed prostate cancer, referred for staging, or with a history of prostate cancer or recent prostate specific antigen (PSA) relapse, referred for the detection of metastatic disease, were included in the present study. None of the patients had known imaging or pathological evidence of metastatic disease prior to FDG PET-CT, however, the PSA levels had been recorded in all patients in the two months prior to FDG PET-CT imaging. Verification of the FDG PET-CT observations was made by biopsy, regional diagnostic CT and/or whole-body bone scintigraphy. The sensitivity of FDG PET-CT in identifying untreated primary lesions was only 33% (3/9). However, FDG PET-CT detected metastatic disease in six of the nine patients who underwent initial staging. Out of 16 patients with previous treatments and recent PSA relapse, FDG PET-CT successfully identified metastatic diseases in 12 and tumor recurrence within the prostatic fossa of two patients. The difference in the PSA levels was identified to be statistically significant between the FDG PET-CT-positive and -negative subgroups of the 16 restaging patients. The results indicated that FDG PET-CT is not useful for the diagnosis of prostate cancer, but may aid with the detection of metastatic disease in appropriately selected patients.

Transperineal ultrasound-guided 12-core prostate biopsy: an extended approach to diagnose transition zone prostate tumors

Objective

Transperineal ultrasound-guided (TPUS) 12-core prostate biopsy was evaluated as an initial strategy for the diagnosis of prostate cancer, The distribution of prostate cancer lesions was assessed with zone-specific biopsy.

Methods

From January 2010 to December 2012, 287 patients underwent TPUS-guided 12-core prostate biopsy. Multiple cores were obtained from both the peripheral zone (PZ) and the transition zone (TZ) of the prostate. Participants' clinical data and the diagnostic yield of the cores were recorded and prospectively analyzed as a cross-sectional study.

Results

The diagnostic yield of the 12-core prostate biopsy was significantly higher compared to the 6-core scheme (42.16 vs. 21.6%). The diagnostic yield of the 10-core prostate biopsy was significantly higher compared to the 6-core scheme (37.6 vs. 21.6%). The 12-core scheme improved the diagnostic yield in prostates >50 ml (12-core scheme: 28.1% vs. 10-core scheme: 20.4%; p = 0.034).

Conclusions

The 12-core biopsy scheme is a safe and effective approach for the diagnosis of prostate cancer. TZ biopsies in patients with larger prostates should be included in the initial biopsy strategy.

Imaging and Markers as Novel Diagnostic Tools in Detecting Insignificant Prostate Cancer: A Critical Overview

Recent therapeutic advances for managing low-risk prostate cancer include the active surveillance and focal treatment. However, locating a tumor and detecting its volume by adequate sampling is still problematic. Development of predictive biomarkers guiding individual therapeutic choices remains an ongoing challenge. At the same time, prostate cancer magnetic resonance imaging is gaining increasing importance for prostate diagnostics. The high morphological resolution of T2-weighted imaging and functional MRI methods may increase the specificity and sensitivity of diagnostics. Also, recent studies founded an ability of novel biomarkers to identify clinically insignificant prostate cancer, risk of progression, and association with poor differentiation and, therefore, with clinical significance. Probably, the above mentioned methods would improve tumor characterization in terms of its volume, aggressiveness, and focality. In this review, we attempted to evaluate the applications of novel imaging techniques and biomarkers in assessing the significance of the prostate cancer.

Electrical property sensing biopsy needle for prostate cancer detection

BACKGROUND

Significant electrical property differences have been demonstrated to exist between malignant and benign prostate tissues. We evaluated how well a custom designed clinically deployable electrical property sensing biopsy needle is able to discriminate between these tissue types in an ex vivo prostate model.

METHODS

An electrical impedance spectroscopy (EIS) sensing biopsy (Bx) needle was developed to record resistive (ρR) and reactive (ρX) components of electrical impedance from 100 Hz to 1 MHz. Standard twelve-core biopsy protocols were followed, in which the EIS-Bx device was used to gauge electrical properties prior to extracting tissue cores through biopsy needle firing from 36 ex vivo human prostates. Histopathological assessment of the cores was statistically compared to the impedance spectrum gauged from each core.

RESULTS

The magnitudes of the mean resistive and reactive components were significantly higher in cancer tissues (P < 0.05). ROC curves showed that ρR at 63.09 kHz was optimal for discriminating cancer from benign tissues; this parameter had 75.4% specificity, 76.1% sensitivity, and ROC AUC of 0.779. Similarly, 251.1 kHz was optimal when using ρX to discriminate cancer from benign tissues; this parameter had a 77.9% specificity, 71.4% sensitivity, and ROC AUC of 0.79.

CONCLUSION

Significant electrical property differences noted between benign and malignant prostate tissues suggest the potential efficacy an EIS-Bx device would provide for cancer detection in a clinical setting. By sensing a greater fraction of the prostate's volume in real-time, the EIS-Bx device has the potential to improve the accuracy of cancer grading and volume estimation made with current biopsy procedures.

Construction and in vitro/in vivo targeting of PSMA-targeted nanoscale microbubbles in prostate cancer

BACKGROUND

Prostate-specific membrane antigen (PSMA) is a highly specific biological marker and treatment target for prostate cancer. So ultrasound molecular imaging using PSMA antibody-loaded targeted nanoscale microbubbles (MBs) may contribute to the early diagnosis of prostate cancer.

METHODS

PSMA monoclonal antibody-loaded targeted nanoscale MBs were prepared using biotin-avidin technology. Antibody binding was evaluated with immunofluorescence. Using MKN45 gastric cancer cells as controls, the targeting capability of the targeted MBs was observed in prostate cancer cells (LNCaP and C4-2) under optical microscope. Contrast enhancement was monitored by an ultrasound system in C4-2, LNCaP, and MKN45 transplanted tumors in nude mice. The arrival time, time to peak, peak intensity, and duration of contrast enhancement of targeted and blank nanoscale MBs were compared and analyzed.

RESULTS

Targeted PSMA monoclonal antibody-loaded nanoscale MBs were successfully synthesized. These MBs were stable and could specifically bind to LNCaP and C4-2 cells in vitro but did not bind to MKN45 cells. There were significant differences in peak intensity and duration of contrast enhancement between targeted and blank nanoscale MBs in both transplanted prostate tumors (P < 0.05). Among the three types of transplanted tumors with targeted nanoscale MBs, the peak intensity was significantly higher in prostate tumors (LNCaP and C4-2) than in gastric tumors (MKN45) (P < 0.05).

CONCLUSIONS

PSMA monoclonal antibody-loaded targeted nanoscale MBs can target and bind to prostate cancer cells specifically and allow for obvious contrast enhancement in vivo. Therefore, this study lays a foundation for early diagnosis and targeted therapy for prostate cancer.

Synthesis and in vitro evaluation of MR molecular imaging probes using J591 mAb-conjugated SPIONs for specific detection of prostate cancer

Carcinoma of the prostate is the most frequent diagnosed malignant tumor in men and is the second leading cause of cancer-related death in this group. The cure rate of prostate cancer is highly dependent on the stage of disease at the diagnosis and early detection is key to designing effective treatment strategies. The objective of the present study is to make a specific MR imaging probe for targeted imaging of cancer cells. We take advantage of the fact that many types of prostate cancer cells express high levels of prostate-specific membrane antigen (PSMA) on their cell surface. The imaging strategy is to use superparamagnetic iron oxide nanoparticles (SPIONs), attached to an antibody (J591) that binds to the extracellular domain of PSMA, to specifically enhance the contrast of PSMA-expressing prostate cancer cells. Conjugation of mAb J591 to commercial SPIONs was achieved using a heterobifunctional linker, sulfo-SMCC. Two types of prostate cancer cell lines were chosen for experiments: LNCaP (PSMA+) and DU145 (PSMA-). MRI and cell uptake experiments demonstrated the high potential of the synthesized nanoprobe as a specific MRI contrast agent for detection of PSMA-expressing prostate cancer cells.

An integrated approach to identify normal tissue expression of targets for antibody-drug conjugates: case study of TENB2

BACKGROUND AND PURPOSE

The success of antibody-drug conjugates (ADCs) depends on the therapeutic window rendered by the differential expression between normal and pathological tissues. The ability to identify and visualize target expression in normal tissues could reveal causes for target-mediated clearance observed in pharmacokinetic characterization. TENB2 is a prostate cancer target associated with the progression of poorly differentiated and androgen-independent tumour types, and ADCs specific for TENB2 are candidate therapeutics. The objective of this study was to locate antigen expression of TENB2 in normal tissues, thereby elucidating the underlying causes of target-mediated clearance.

EXPERIMENTAL APPROACH

A series of pharmacokinetics, tissue distribution and mass balance studies were conducted in mice using a radiolabelled anti-TENB2 ADC. These data were complemented by non-invasive single photon emission computed tomography - X-ray computed tomography imaging and immunohistochemistry.

KEY RESULTS

The intestines were identified as a saturable and specific antigen sink that contributes, at least in part, to the rapid target-mediated clearance of the anti-TENB2 antibody and its drug conjugate in rodents. As a proof of concept, we also demonstrated the selective disposition of the ADC in a tumoural environment in vivo using the LuCaP 77 transplant mouse model. High tumour uptake was observed despite the presence of the antigen sink, and antigen specificity was confirmed by antigen blockade.

CONCLUSIONS AND IMPLICATIONS

Our findings provide the anatomical location and biological interpretation of target-mediated clearance of anti-TENB2 antibodies and corresponding drug conjugates. Further investigations may be beneficial in addressing the relative contributions to ADC disposition from antigen expression in both normal and pathological tissues.

Functional and molecular imaging: applications for diagnosis and staging of localised prostate cancer

Prostate cancer is currently the most common solid organ cancer type among men in the Western world. Currently, all decision-making algorithms and nomograms rely on demographics, clinicopathological data and symptoms. Such an approach can easily miss significant cancers while detecting many insignificant cancers. In this review, novel functional and molecular imaging techniques used in the diagnosis and staging of localised prostate cancer and their effect on treatment decisions are discussed.

Pretargeted immuno-PET and radioimmunotherapy of prostate cancer with an anti-TROP-2 x anti-HSG bispecific antibody

PURPOSE

TF12 is a trivalent bispecific antibody that consists of two anti-TROP-2 Fab fragments and one anti-histamine-succinyl-glycine (HSG) Fab fragment. The TROP-2 antigen is found in many epithelial cancers, including prostate cancer (PC), and therefore this bispecific antibody could be suitable for pretargeting in this cancer. In this study, the characteristics and the potential for pretargeted radioimmunoimaging and radioimmunotherapy with TF12 and the radiolabeled di-HSG peptide IMP288 in mice with human PC were investigated.

METHODS

The optimal TF12 protein dose, IMP288 peptide dose, and dose interval for PC targeting were assessed in nude mice with s.c. PC3 xenografts. Immuno-positron emission tomography (PET)/CT was performed using TF12/⁶⁸Ga-IMP288 at optimized conditions. The potential of pretargeted radioimmunotherapy (PRIT) using the TF12 pretargeted ¹⁷⁷Lu-IMP288 was determined.

RESULTS

TF12 and ¹¹¹In-IMP288 showed high and fast accumulation in the tumor [20.4 ± 0.6%ID/g at 1 h post-injection (p.i.)] at optimized conditions, despite the internalizing properties of TF12. The potential for PRIT was shown by retention of 50% of the ¹¹¹In-IMP288 in the tumor at 48 h p.i. One cycle of treatment with TF12 and ¹⁷⁷Lu-IMP288 showed significant improvement of survival compared to treatment with ¹⁷⁷Lu-IMP288 alone (90 vs. 67 days, p<0.0001) with no renal or hematological toxicity.

CONCLUSION

TROP-2-expressing PC can be pretargeted efficiently with TF12, with very rapid uptake of the radiolabeled hapten-peptide, IMP288, sensitive immuno-PET, and effective therapy.

Multiparametric magnetic resonance imaging of prostate cancer

In India, prostate cancer has an incidence rate of 3.9 per 100,000 men and is responsible for 9% of cancer-related mortality. It is the only malignancy that is diagnosed with an apparently blind technique, i.e., transrectal sextant biopsy. With increasing numbers of high-Tesla magnetic resonance imaging (MRI) equipment being installed in India, the radiologist needs to be cognizant about endorectal MRI and multiparametric imaging for prostate cancer. In this review article, we aim to highlight the utility of multiparamteric MRI in prostate cancer. It plays a crucial role, mainly in initial staging, restaging, and post-treatment follow-up.

The role of 11C-choline and 18F-fluorocholine positron emission tomography (PET) and PET/CT in prostate cancer: a systematic review and meta-analysis

CONTEXT

The role of positron emission tomography (PET) and PET/computed tomography (PET/CT) in prostate cancer (PCa) imaging is still debated, although guidelines for their use have emerged over the last few years.

OBJECTIVE

To systematically review and conduct a meta-analysis of the available evidence of PET and PET/CT using 11C-choline and 18F-fluorocholine as tracers in imaging PCa patients in staging and restaging settings.

EVIDENCE ACQUISITION

PubMed, Embase, and Web of Science (by citation of reference) were searched. Reference lists of review articles and included articles were checked to complement electronic searches.

EVIDENCE SYNTHESIS

In staging patients with proven but untreated PCa, the results of the meta-analysis on a per-patient basis (10 studies, n = 637) showed pooled sensitivity, specificity, and diagnostic odds ratio (DOR) of 84% (95% confidence interval [CI], 68-93%), 79% (95% CI, 53-93%), and 20.4 (95% CI, 9.9-42.0), respectively. The positive and negative likelihood ratios were 4.02 (95% CI, 1.73-9.31) and 0.20 (95% CI, 0.11-0.37), respectively. On a per-lesion basis (11 studies, n = 5117), these values were 66% (95% CI, 56-75%), 92% (95% CI, 78-97%), and 22.7 (95% CI, 8.9-58.0), respectively, for pooled sensitivity, specificity, and DOR; and 8.29 (95% CI, 3.05-22.54) and 0.36 (95% CI, 0.29-0.46), respectively, for positive and negative likelihood ratios. In restaging patients with biochemical failure after local treatment with curative intent, the meta-analysis results on a per-patient basis (12 studies, n = 1055) showed pooled sensitivity, specificity, and DOR of 85% (95% CI, 79-89%), 88% (95% CI, 73-95%), and 41.4 (95% CI, 19.7-86.8), respectively; the positive and negative likelihood ratios were 7.06 (95% CI, 3.06-16.27) and 0.17 (95% CI, 0.13-0.22), respectively.

CONCLUSIONS

PET and PET/CT imaging with 11C-choline and 18F-fluorocholine in restaging of patients with biochemical failure after local treatment for PCa might help guide further treatment decisions. In staging of patients with proven but untreated, high-risk PCa, there is limited but promising evidence warranting further studies. However, the current evidence shows crucial limitations in terms of its applicability in common clinical scenarios.

Magnetic resonance imaging for prostate cancer clinical application

As prostate cancer is a biologically heterogeneous disease for which a variety of treatment options are available, the major objective of prostate cancer imaging is to achieve more precise disease characterization. In clinical practice, magnetic resonance imaging (MRI) is one of the imaging tools for the evaluation of prostate cancer, the fusion of MRI or dynamic contrast-enhanced MRI (DCE-MRI) with magnetic resonance spectroscopic imaging (MRSI) is improving the evaluation of cancer location, size, and extent, while providing an indication of tumor aggressiveness. This review summarizes the role of MRI in the application of prostate cancer and describes molecular MRI techniques (including MRSI and DCE-MRI) for aiding prostate cancer management.

[Imaging diagnostics of advanced prostate cancer]

The diagnostic approach to prostate cancer is still a big challenge for the treating physician. Regarding an individualized and risk-adapted evaluation of different therapeutic options, precise diagnostic tools are crucial to accurately distinguish between localized and advanced prostate cancer. Imaging of advanced prostate cancer is currently changing due to numerous technical innovations. While choline-based hybrid positron emission tomography-computed tomography (PET/CT) has been established as an important diagnostic tool in clinical imaging of advanced prostate cancer, well-investigated methods, such as magnetic resonance imaging (MRI) and bone scintigraphy are currently expanding the diagnostic potential due to technical improvements. The specific use of imaging for advanced prostate cancer may help to offer the patient a well-tailored oncologic therapy. Further research is needed to evaluate whether this individualized therapy can consistently improve the prognosis of patients suffering from advanced prostate cancer.

Nanoparticle PET/CT imaging of natriuretic peptide clearance receptor in prostate cancer

Atrial natriuretic peptide has been recently discovered to have anticancer effects via interaction with cell surface natriuretic peptide receptor A (NPRA) and natriuretic peptide clearance receptor (NPRC). In a preclinical model, NPRA expression has been identified during tumor angiogenesis and may serve as a potential prognostic marker and target for prostate cancer (PCa) therapy. However, the presence of NPRC receptor in the PCa model has not yet been assessed. Furthermore, there is still no report using nanoparticle for PCa positron emission tomography (PET) imaging. Herein, an amphiphilic comb-like nanoparticle was synthesized with controlled properties through modular construction containing C-atrial natriuretic factor (CANF) for NPRC receptor targeting and 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) chelator for high specific activity Cu-64 radiolabeling. The pharmacokinetics of (64)Cu-CANF-Comb exhibited tuned biodistribution and optimized in vivo profile in contrast to the nontargeted (64)Cu-Comb nanoparticle. PET imaging with (64)Cu-CANF-Comb in CWR22 PCa tumor model showed high blood pool retention, low renal clearance, enhanced tumor uptake, and decreased hepatic burden relative to the nontargeted (64)Cu-Comb. Immunohistochemistry staining confirmed the presence of NPRC receptor in tumor tissue. Competitive PET receptor blocking study demonstrated the targeting specificity of (64)Cu-CANF-Comb to NPRC receptor in vivo. These results establish a new nanoagent for prostate cancer PET imaging.

Prostate cancer imaging: what the urologist wants to know

No consensus exists at present regarding the use of imaging for the evaluation of prostate cancer. Ultrasonography is mainly used for biopsy guidance and magnetic resonance imaging is the mainstay in evaluating the extent of local tumor. Computed tomography and radionuclide bone scanning are mainly reserved for assessment of advanced disease. Positron emission tomography is gaining acceptance in the evaluation of treatment response and recurrence. The combination of anatomic, functional, and metabolic imaging modalities has promise to improve treatment. This article reviews current imaging techniques and touches on the evolving technologies being used for detection and follow-up of prostate cancer.

Imaging in prostate cancer staging: present role and future perspectives

Despite recent improvements in detection and treatment, prostate cancer continues to be the most common malignancy and the second leading cause of cancer-related mortality. Thus, although survival rate continues to improve, prostate cancer remains a compelling medical health problem. The major goal of prostate cancer imaging in the next decade will be more accurate disease characterization through the synthesis of anatomic, functional, and molecular imaging information in order to plan the most appropriate therapeutic strategy. No consensus exists regarding the use of imaging for evaluating primary prostate cancer. However, conventional and functional imaging are expanding their role in detection and local staging and, moreover, functional imaging is becoming of great importance in oncologic management and monitoring of therapy response. This review presents a multidisciplinary perspective on the role of conventional and functional imaging methods in prostate cancer staging.

Impact of drug conjugation on pharmacokinetics and tissue distribution of anti-STEAP1 antibody-drug conjugates in rats

Antibody-drug conjugates (ADCs) are designed to combine the exquisite specificity of antibodies to target tumor antigens with the cytotoxic potency of chemotherapeutic drugs. In addition to the general chemical stability of the linker, a thorough understanding of the relationship between ADC composition and biological disposition is necessary to ensure that the therapeutic window is not compromised by altered pharmacokinetics (PK), tissue distribution, and/or potential organ toxicity. The six-transmembrane epithelial antigen of prostate 1 (STEAP1) is being pursued as a tumor antigen target. To assess the role of ADC composition in PK, we evaluated plasma and tissue PK profiles in rats, following a single dose, of a humanized anti-STEAP1 IgG1 antibody, a thio-anti-STEAP1 (ThioMab) variant, and two corresponding thioether-linked monomethylauristatin E (MMAE) drug conjugates modified through interchain disulfide cysteine residues (ADC) and engineered cysteines (TDC), respectively. Plasma PK of total antibody measured by enzyme-linked immunosorbent assay (ELISA) revealed ∼45% faster clearance for the ADC relative to the parent antibody, but no apparent difference in clearance between the TDC and unconjugated parent ThioMab. Total antibody clearances of the two unconjugated antibodies were similar, suggesting minimal effects on PK from cysteine mutation. An ELISA specific for MMAE-conjugated antibody indicated that the ADC cleared more rapidly than the TDC, but total antibody ELISA showed comparable clearance for the two drug conjugates. Furthermore, consistent with relative drug load, the ADC had a greater magnitude of drug deconjugation than the TDC in terms of free plasma MMAE levels. Antibody conjugation had a noticeable, albeit minor, impact on tissue distribution with a general trend toward increased hepatic uptake and reduced levels in other highly vascularized organs. Liver uptakes of ADC and TDC at 5 days postinjection were 2-fold and 1.3-fold higher, respectively, relative to the unmodified antibodies. Taken together, these results indicate that the degree of overall structural modification in anti-STEAP1-MMAE conjugates has a corresponding level of impact on both PK and tissue distribution.

Imaging of prostate cancer with immuno-PET and immuno-SPECT using a radiolabeled anti-EGP-1 monoclonal antibody

hRS7 is a humanized IgG1 monoclonal antibody directed against the epithelial glycoprotein-1 (EGP-1; also known as TROP2). This antigen is found in many epithelial cancers, including prostate cancer, and therefore this antibody could be suitable for targeting this cancer. In this study, the characteristics of hRS7 for targeting prostate cancer were examined. The potential for immuno-PET with (89)Zr-hRS7 and immuno-SPECT with (111)In-hRS7 was assessed using nude mice with human prostate cancer xenografts.

METHODS

EGP-1 expression was assessed by immunohistology in human primary and metastatic prostate cancer samples and in PC3 xenografts. The optimal antibody protein dose for prostate cancer targeting was examined in nude mice with subcutaneous PC3 xenografts, and then the biodistribution of (111)In-, (125)I-, and (89)Zr-labeled hRS7 was determined in subcutaneous PC3 xenografts at 1, 3, and 7 d after injection. Immuno-PET and immuno-SPECT were performed with (89)Zr-hRS7 and (111)In-hRS7 in mice with subcutaneous and intraprostatic PC3 xenografts, respectively.

RESULTS

Immunohistochemical analysis showed abundant EGP-1 expression in human primary and metastatic prostate cancers and in PC3 xenografts. (111)In-hRS7 and (89)Zr-hRS7 preferentially and specifically accumulated in PC3 xenografts, with tumor uptake as high as 60% injected dose per gram at a protein dose of 0.1 μg per mouse. PC3 tumors in nude mice were clearly visualized with both tracers with immuno-PET and immuno-SPECT.

CONCLUSION

hRS7 shows excellent in vivo tumor targeting in human prostate cancer xenografts. Therefore, hRS7 is a potential vehicle for targeting prostate cancer.

18F-labeled bombesin analog for specific and effective targeting of prostate tumors expressing gastrin-releasing peptide receptors

Bombesin is a peptide exhibiting high affinity for the gastrin-releasing peptide receptor (GRPr), which is highly overexpressed on prostate cancer cells. In the present study, we developed an (18)F-labeled bombesin analog, (18)F-BAY 86-4367, which is currently being clinically tested for use in PET of prostate cancer.

METHODS

In vitro pharmacologic studies were performed to characterize the nonradioactive ((19)F) standard of the bombesin analog for binding affinity and selectivity for GRPr. The stability of (18)F-BAY 86-4367 was determined in murine and human plasma. In vivo, the tumor-targeting potential and pharmacokinetic profile of the (18)F tracer were analyzed with biodistribution experiments and PET studies of prostate tumor-bearing mice.

RESULTS

The nonradioactive ((19)F) standard of the bombesin analog showed subnanomolar and GRPr-selective binding affinity. The stability of the tracer in murine and human plasma was found to be high. In 2 prostate cancer xenograft models (PC-3 and LNCaP), (18)F-BAY 86-4367 showed more specific and effective GRPr-based targeting in vivo than the benchmark radiotracers (18)F-fluoroethylcholine and (18)F-FDG. In addition, rapid tumor targeting and fast renal excretion (∼70%) and hepatobiliary excretion (∼10%) were identified in both xenograft models. Furthermore, PET studies provided clear and specific visualization of PC-3 tumors in mice.

CONCLUSION

Favorable preclinical data showing specific and effective tumor targeting by (18)F-BAY 86-4367 suggest that a clinical trial be undertaken to test its diagnostic utility in PET for prostate carcinoma patients.

MR to ultrasound registration for image-guided prostate interventions

A deformable registration method is described that enables automatic alignment of magnetic resonance (MR) and 3D transrectal ultrasound (TRUS) images of the prostate gland. The method employs a novel "model-to-image" registration approach in which a deformable model of the gland surface, derived from an MR image, is registered automatically to a TRUS volume by maximising the likelihood of a particular model shape given a voxel-intensity-based feature that represents an estimate of surface normal vectors at the boundary of the gland. The deformation of the surface model is constrained by a patient-specific statistical model of gland deformation, which is trained using data provided by biomechanical simulations. Each simulation predicts the motion of a volumetric finite element mesh due to the random placement of a TRUS probe in the rectum. The use of biomechanical modelling in this way also allows a dense displacement field to be calculated within the prostate, which is then used to non-rigidly warp the MR image to match the TRUS image. Using data acquired from eight patients, and anatomical landmarks to quantify the registration accuracy, the median final RMS target registration error after performing 100 MR-TRUS registrations for each patient was 2.40 mm.

[Type and extent of preoperative imaging before radical prostatectomy]

BACKGROUND

According to current guidelines, in cases of newly diagnosed prostate cancer the type and extent of imaging to be performed should be based on the patient's risk profile. We investigated the rate of computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy carried out before radical prostatectomy (RP) depending on the individual risk profile.

PATIENTS AND METHOD

Between 1 January 2006 and 31 December 2007, a total of 1,018 consecutive patients who had not received neoadjuvant hormone therapy were treated with RP in our department. We determined the preoperative rates of CT, MRI, and bone scintigraphy by reviewing the medical charts. The patients were stratified according to the D'Amico criteria into low-risk, intermediate-risk, and high-risk groups.

RESULTS

Of the 1,018 subjects, 493 (48%) were classified as low-risk, 403 (40%) as intermediate-risk, and 122 (12%) as high-risk patients, respectively. The rate of preoperative abdominal CT/MRI and bone scintigraphy was 17 and 23% in the low-risk group, 25 and 39% in the intermediate-risk patients, and 39 and 57% in the high-risk group.

CONCLUSION

The rate of preoperative CT and bone scintigraphy is extremely high in the low-risk group. In contrast the rate in the high-risk patients more likely appears to be too low. The discrepancy between the rates of preoperative imaging subject to the patient's risk profile shows that precisely formulated guidelines addressing this issue are needed.

Update on prostate imaging

Successful and accurate imaging of prostate cancer is integral to its clinical management from detection and staging to subsequent monitoring. Various modalities are used including ultrasound, computed tomography, and magnetic resonance imaging, with the greatest advances seen in the field of magnetic resonance.

Targeting prostate cancer cells in vivo using a rapidly internalizing novel human single-chain antibody fragment

Human antibodies targeting prostate cancer cell surface epitopes may be useful for imaging and therapy. The objective of this study was to evaluate the tumor targeting of an internalizing human antibody fragment, a small-size platform, to provide high contrast in a mouse model of human prostate carcinoma.

METHODS

A prostate tumor-targeting single-chain antibody fragment (scFv), UA20, along with a nonbinding control scFv, N3M2, were labeled with (99m)Tc and evaluated for binding and rapid internalization into human prostate tumor cells in vitro and tumor homing in vivo using xenograft models. For the in vitro studies, the labeled UA20 scFv was incubated at 37 degrees C for 1 h with metastatic prostate cancer cells (DU145) to assess the total cellular uptake versus intracellular uptake. For the animal studies, labeled UA20 and N3M2 scFvs were administered to athymic mice implanted subcutaneously with DU145 cells. Mice were imaged with small-animal SPECT/CT with concomitant biodistribution at 1 and 3 h after injection.

RESULTS

The UA20 scFv was labeled in 55%-65% yield and remained stable in phosphate buffer within 24 h. The labeled UA20 scFv was taken up specifically by prostate tumor cells. Internalization was rapid, because incubation at 37 degrees C for less than 1 h resulted in 93% internalization of total cell-associated scFvs. In animal studies, SPECT/CT showed significant tumor uptake as early as 1 h after injection. At 3 h after injection, tumor uptake was 4.4 percentage injected dose per gram (%ID/g), significantly greater than all organs or tissues studied (liver, 2.7 %ID/g; other organs or tissues, <1 %ID/g), except the kidneys (81.4 %ID/g), giving tumor-to-blood and tumor-to-muscle ratios of 12:1 and 70:1, respectively. In contrast, the control antibody exhibited a tumor uptake of only 0.26 %ID/g, similar to that of muscle and fat. Tumor-specific targeting was evidenced by reduced tumor uptake of nearly 70% on administration of a 10-fold excess of unlabeled UA20 scFv. Kidney uptake was nonspecific, consistent with the route of excretion by scFvs.

CONCLUSION

The UA20 scFv showed rapid and specific internalization in prostate tumor cells in vitro and accumulation in prostate tumor xenografts in vivo, demonstrating the potential for future development for prostate cancer imaging and targeted therapy.