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In prostate cancer (PCa) patients, the tumor-to-blood ratio (TBR) has been validated as the preferred simplified method for lesional 18 F-DCFPyL (a radiolabeled prostate-specific membrane antigen ligand) uptake quantification on PET. In contrast to SUVs, the TBR accounts for variability in arterial input functions caused by differences in total tumor burden between patients (the sink effect). However, TBR depends strongly on tracer uptake interval and has worse repeatability and is less applicable in clinical practice than SUVs. We investigated whether SUV could provide adequate quantification of 18 F-DCFPyL uptake on PET/CT in a patient cohort with low PCa burden. Methods: In total, 116 patients with PCa undergoing 18 F-DCFPyL PET/CT imaging were retrospectively included. All 18 F-DCFPyL-avid lesions suspected of being PCa were semiautomatically delineated. SUV peak was plotted against TBR for the most intense lesion of each patient. The correlation of SUV peak and TBR was evaluated using linear regression and was stratified for patients undergoing PET/CT for primary staging, patients undergoing restaging at biochemical recurrence, and patients with metastatic castration-resistant PCa. Moreover, the correlation was evaluated as a function of tracer uptake time, prostate-specific antigen level, and PET-positive tumor volume. Results: In total, 436 lesions were delineated (median, 1 per patient; range, 1-66). SUV peak correlated well with TBR in patients with PCa and a total tumor volume of less than 200 cm 3 ( R 2 = 0.931). The correlation between SUV and TBR was not affected by disease setting, prostate-specific antigen level, or tumor volume. SUV peak depended less on tracer uptake time than did TBR. Conclusion: For 18 F-DCFPyL PET/CT, SUV peak correlates strongly with TBR. Therefore, it is a valuable simplified, semiquantitative measurement in patients with low-volume PCa (<200 cm 3 ). SUV peak can therefore be applied in 18 F-DCFPyL PET assessment as an imaging biomarker to characterize tumors and to monitor treatment outcomes., (© 2021 by the Society of Nuclear Medicine and Molecular Imaging.)

Quantitative evaluation of radiolabeled prostate-specific membrane antigen (PSMA) PET scans may be used to monitor treatment response in patients with prostate cancer (PCa). To interpret longitudinal differences in PSMA uptake, the intrinsic variability of tracer uptake in PCa lesions needs to be defined. The aim of this study was to investigate the repeatability of quantitative PET/CT measurements using 18 F-DCFPyL ([2-(3-(1-carboxy-5-[(6- 18 F-fluoro-pyridine-3-carbonyl)-amino]-pentyl)-ureido)-pentanedioic acid], a second-generation 18 F-PSMA-ligand) in patients with PCa. Methods: Twelve patients with metastatic PCa were prospectively included, of whom 2 were excluded from final analyses. Patients received 2 whole-body 18 F-DCFPyL PET/CT scans (median dose, 317 MBq; uptake time, 120 min) within a median of 4 d (range, 1-11 d). After semiautomatic (isocontour-based) tumor delineation, the following lesion-based metrics were derived: mean, peak, and maximum tumor-to-blood ratio; SUV mean , SUV peak , and SUV max normalized to body weight; tumor volume; and total lesion uptake (TLU). Additionally, patient-based total tumor volume (TTV) (sum of PSMA-positive tumor volumes) and total tumor burden (TTB) (sum of all lesion TLUs) were derived. Repeatability was analyzed using repeatability coefficients (RC) and intraclass correlation coefficients. Additionally, the effect of point-spread function (PSF) image reconstruction on the repeatability of uptake metrics was evaluated. Results: In total, 36 18 F-DCFPyL PET-positive lesions were analyzed (≤5 lesions per patient). The RCs for mean, peak, and maximum tumor-to-blood ratio were 31.8%, 31.7%, and 37.3%, respectively. For SUV mean , SUV peak , and SUV max , the RCs were 24.4%, 25.3%, and 31.0%, respectively. All intraclass correlation coefficients were at least 0.97. Tumor volume delineations were quite repeatable, with an RC of 28.1% for individual lesion volumes and 17.0% for TTV. TTB had an RC of 23.2% and 33.4% when based on SUV mean and mean tumor-to-blood ratio, respectively. Small lesions (<4.2 cm 3 ) had worse repeatability for volume measurements. The repeatability of SUV peak , TLU, and all patient-level metrics was not affected by PSF reconstruction. Conclusion: 18 F-DCFPyL uptake measurements are quite repeatable and can be used for clinical validation in future treatment response assessment studies. Patient-based TTV may be preferred for multicenter studies because its repeatability was both high and robust to different image reconstructions., (© 2020 by the Society of Nuclear Medicine and Molecular Imaging.)

Radiolabeled prostate-specific membrane antigen (PSMA) PET has demonstrated promising results for prostate cancer (PCa) imaging. Quantification of PSMA radiotracer uptake is desired as it enables reliable interpretation of PET images, use of PSMA uptake as an imaging biomarker for tumor characterization, and evaluation of treatment effects. The aim of this study was to perform a full pharmacokinetic analysis of 2-(3-(1-carboxy-5-[(6- 18 F-fluoro-pyridine-3-carbonyl)-amino]-pentyl)-ureido)-pentanedioic acid ( 18 F-DCFPyL), a second-generation 18 F-labeled PSMA ligand. On the basis of the pharmacokinetic analysis (reference method), simplified methods for quantification of 18 F-DCFPyL uptake were validated. Methods: Eight patients with metastasized PCa were included. Dynamic PET acquisitions were performed at 0-60 and 90-120 min after injection of a median dose of 313 MBq of 18 F-DCFPyL (range, 292-314 MBq). Continuous and manual arterial blood sampling provided calibrated plasma tracer input functions. Time-activity curves were derived for each PCa metastasis, and 18 F-DCFPyL kinetics were described using standard plasma input tissue-compartment models. Simplified methods for quantification of 18 F-DCFPyL uptake (SUVs; tumor-to-blood ratios [TBRs]) were correlated with kinetic parameter estimates obtained from full pharmacokinetic analysis. Results: In total, 46 metastases were evaluated. A reversible 2-tissue-compartment model was preferred for 18 F-DCFPyL kinetics in 59% of the metastases. The observed k 4 was small, however, resulting in nearly irreversible kinetics during the course of the PET study. Hence, k 4 was fixated (0.015) and net influx rate, K i , was preferred as the reference kinetic parameter. Whole-blood TBR provided an excellent correlation with K i from full kinetic analysis ( R 2 = 0.97). This TBR could be simplified further by replacing the blood samples with an image-based, single measurement of blood activity in the ascending aorta (image-based TBR, R 2 = 0.96). SUV correlated poorly with K i ( R 2 = 0.47 and R 2 = 0.60 for SUV normalized to body weight and lean body mass, respectively), most likely because of deviant blood activity concentrations (i.e., tumor tracer input) in patients with higher tumor volumes. Conclusion: 18 F-DCFPyL kinetics in PCa metastases are best described by a reversible 2-tissue-compartment model. Image-based TBRs were validated as a simplified method to quantify 18 F-DCFPyL uptake and might be applied to clinical, whole-body PET scans. SUV does not provide reliable quantification of 18 F-DCFPyL uptake., (© 2019 by the Society of Nuclear Medicine and Molecular Imaging.)

PET is increasingly used for prostate cancer (PCa) diagnostics. Important PCa radiotracers include 68 Ga-prostate-specific membrane antigen HBED-CC ( 68 Ga-PSMA), 18 F-DCFPyL, 18 F-fluoromethylcholine ( 18 F-FCH), and 18 F-dihydrotestosterone ( 18 F-FDHT). Knowledge on the variability of tracer uptake in healthy tissues is important for accurate PET interpretation, because malignancy is suspected only if the uptake of a lesion contrasts with its background. Therefore, the aim of this study was to quantify uptake variability of PCa tracers in healthy tissues and identify stable reference regions for PET interpretation. Methods: A total of 232 PCa PET/CT scans from multiple hospitals was analyzed, including 87 68 Ga-PSMA scans, 50 18 F-DCFPyL scans, 68 18 F-FCH scans, and 27 18 F-FDHT scans. Tracer uptake was assessed in the blood pool, lung, liver, bone marrow, and muscle using several SUVs (SUV max , SUV mean , SUV peak ). Variability in uptake between patients was analyzed using the coefficient of variation (COV%). For all tracers, SUV reference ranges (95th percentiles) were calculated, which could be applicable as image-based quality control for future PET acquisitions. Results: For 68 Ga-PSMA, the lowest uptake variability was observed in the blood pool (COV, 19.9%), which was significantly more stable than all other tissues (COV, 29.8%-35.2%; P = 0.001-0.024). For 18 F-DCFPyL, the lowest variability was observed in the blood pool and liver (COV, 14.4% and 21.7%, respectively; P = 0.001-0.003). The least variable 18 F-FCH uptake was observed in the liver, blood pool, and bone marrow (COV, 16.8%-24.2%; P = 0.001-0.012). For 18 F-FDHT, low uptake variability was observed in all tissues, except the lung (COV, 14.6%-23.6%; P = 0.001-0.040). The different SUV types had limited effect on variability (COVs within 3 percentage points). Conclusion: In this multicenter analysis, healthy tissues with limited uptake variability were identified, which may serve as reference regions for PCa PET interpretation. These reference regions include the blood pool for 68 Ga-PSMA and 18 F-DCFPyL and the liver for 18 F-FCH and 18 F-FDHT. Healthy tissue SUV reference ranges are presented and applicable as image-based quality control., (© 2019 by the Society of Nuclear Medicine and Molecular Imaging.)