Clinical Value of FEC-PET Combined With Endorectal MRI for Pre-therapeutic Staging of Prostate Cancer

NCT ID: NCT00520546

Last Updated: 2012-06-20

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: PHASE3
• Total Enrollment: 44 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2007-12-31
• Study Completion Date: 2011-06-30

Brief Summary

To investigate the sensitivity of the [18F]fluoroethylcholine (FEC) Positron-Emission-Tomography/ Magnetic Resonance Imaging (PET/MRI) method in tumour detection and location (side assignment, encapsulation, invasion of the seminal vesicle) and detection of affected lymph nodes, and to compare these with presently used detection procedures (needle biopsy, digital rectal examination, transrectal ultrasound, and pre-therapeutic assessment), with a view to finding out whether the [18F]fluoroethylcholine PET/MRI method is comparable to, or superior to, the established method. Postoperative histology served as the standard of reference.

Detailed Description

Prostate carcinoma is today in Germany the most frequently diagnosed cancer disease of men and is - after bronchial carcinoma - their second most frequent cause of cancer-related death. Around 22% of all new cancer diagnoses among males are prostate-related. This corresponds to an age-adjusted incidence rate of nearly 100 per 100,000 males in the population, and to well above 40,000 new diagnoses of prostate cancer per year [Robert-Koch-Institut, 2010]. The dramatic increase in recent decades is attributable more to improved diagnostic methods and a generally increased life expectancy than to an actual increase in the incidence of disease [Robert-Koch-Institut, 2010].

The total annual mortality rate is around 11,000 [Statistisches Bundesamt, 1994]. Prostate carcinoma is virtually unknown among men under 40 years of age. The annual prevalence rises with increasing age - between the 40th and 80th years of life by a factor of more than 1000. Autopsies have shown that among men over 70 up to 80% have a latent prostate carcinoma, without it being fatal [Breslow 1977; Börgemann, 2006]. The patients' average age at diagnosis is 71 years.

The five-year prostate-cancer-specific survival rate after diagnosis is about 80-99% for tumours that are restricted to the gland itself [Porter, 2006]. For disseminated tumours this figure is considerably smaller, not more than 35% [von Eschenbach, 1996]. A prospect of complete regression exists only for non-metastasing carcinomas, but there it is quite good: under aggressive treatment, 90% of cancers restricted to the prostate itself can be completely cured, as can 50% of those that have crossed the gland's capsule [Deutsche Gesellschaft für Urologie, 2009].

At present, there is a lack of adequate pre-therapeutic staging methods. This in turn often prevents the reliable choice of a stage-adapted therapeutic regimen, which could possibly offer a better prognosis even for carcinomas extending into neighbouring organs. A consequence of this uncertainty is that in individual cases the therapy is not ideally suited to the stage of disease, and the success of radiation treatment, hormonal therapy and chemotherapy can only approximately be matched with the stage of dissemination. Until now, the only reliable method for lymph-node diagnosis is operative staging by lymphadenectomy. No reliable diagnostic method is available by which the degree of spreading of the tumour within the prostate can be established.

In this context, Positron-Emission-Tomography (PET) examination with radioactively labelled choline appears to offer a promising primary imaging-diagnostic staging method, as indicated by the studies reviewed below. This diagnostic method as applied to humans was first described by Gauthier et al. [1985]. This was followed by two detailed reports from a Japanese group: Hara et al. [1997] first investigated the potential of [11C]choline in brain tumours and found a clear enrichment of this marker in the tumours of 24 patients, while normal brain tissue was not enriched with it. In a subsequent study by the same group [Hara, 1998], the enrichment of fluorodeoxyglucose was compared with the choline uptake in the lesions of ten prostate-cancer patients. Thus, the choline enrichment (SUV, standardised uptake value) was 3.48 ± 1.31 in 43 lesions, while in the normal environment of the lesser pelvis the corresponding value was below 1.0. De Jong et al. [2003] investigated 67 patients, of whom 15 had histologically confirmed lymph-node metastases: the [11C]choline test gave a 'true positive' result in 12 of 15 patients and a 'false negative' in 3 patients, thus indicating that [11C]choline PET is sufficiently sensitive and specific for the pre-operative staging of lymph-node metastases of prostate carcinoma. In a pre-operative staging using Magnetic Resonance Imaging (MRI) with a combined endorectal and body-phased-array coil, Pegios et al. [2003] investigated 42 patients with strong clinical suspicion, or with needle-biopsy confirmation, of prostate cancer and were able to differentiate between stages of extracapsular growth and seminal-vesicle infiltration (tumor stage T2 versus T3 [T2=tumor restricted to the gland itself; T3a=extracapsule growing of the tumor; T3b= tumor infiltration into the seminal-vesicles]) with an accuracy of 94-97% (sensitivity 100%, specificity between 87% and 93% for observers 1 and 2). The exact, local tumour stage was identified with an accuracy of 75%. However, for lymph-node infiltration a sensitivity of only 25% was achieved: one of four lymph-node-positive patients was correctly identified. In a more recent study, a Japanese group [Yamaguchi, 2005] investigated the application of nuclear magnetic resonance (NMR) spectroscopy, magnetic resonance imaging (MRI) and choline-PET in 20 patients with needle-biopsy-confirmed prostate cancer. The PET imaging achieved a sensitivity of 100%, NMR (quotient [(creatine + choline) / citrate]) 65% and unsupported MRI 60%. For 16 patients radical prostatectomy was performed; results correlated with those of pre-operative local staging with PET by 81%, and with MRI by 50%. The site of choline uptakes in PET was visualised by MRI using the distance of the prostate from the femoral head and the pubic symphysis.At present, no data relevant for the present study indication are available on the software-fused imaging by combined PET/MRI. The combination of high-resolution endorectal MRI with functional PET imaging could come to offer a decisive advantage in the staging of prostate carcinoma. The present study was designed to test this in an appropriate patient population.

A system combining PET and MRI was recently granted approval in the U.S.A. by the U.S. Food and Drug Administration [FDA, 2011].

Conditions

Prostate Cancer

Study Design

• Allocation Method: NA
• Intervention Model: SINGLE_GROUP
• Primary Study Purpose: DIAGNOSTIC
• Blinding Strategy: NONE

Study Groups

1

Patients with prostate carcinoma confirmed by needle biopsy, age \>50 years, planned radical prostatectomy with lymph-node dissection, fasting for \>12 hours before FEC-PET and an interval between biopsy and PET \>3 weeks.

Group Type: EXPERIMENTAL

18F-Ethylcholine Positron Emission Tomography (FEC-PET)

Intervention Type: OTHER

PET scans were performed on a LSO scanner (ECAT ACCEL, Siemens, Erlangen, Germany) by using a multiphase protocol starting with a "cold" transmission scan of the lower pelvis. This was followed by a list mode emission scan with 10 frames à 1 minute starting immediately after the administration of 3.3MBq \[18F\]Fluoroethylcholine chloride (FEC; Eckert \& Ziegler EURO-PET Berlin GmbH) as a bolus through the cubital vein. After a short gap due to computer processing time the whole body scan was performed starting at the upper thoracic aperture down to the proximal femur. Acquisition parameters were 3 minutes emission scan and 2 minutes transmission scan for each bed position. Therefore the prostate region was scanned again at 45 minutes p.i. (post injection) A delayed local acquisition at 65 minutes over the lower pelvis with 6 minutes emission and 2 minutes transmission finished the diagnostic acquisition procedure.

Endorectal Magnetic Resonance Imaging (1.5Tesla) (eMRI)

Intervention Type: OTHER

The MRI examination was performed on a 1.5Tesla MRI system (Gyroscan ACS-NT, Philips, Hamburg, Germany) with combined QBody and endorectal coil. Pelvic assessment and lymph node staging was effected with 5mm T2 weighted (T2w) turbo spin echo (TSE) transversal and a coronal short-tau inversion recovery (STIR) sequence. For prostate assessment, 3mm endorectal T2w spin echo (SE) sagittal, transversal and coronal sequences were acquired.

Interventions

18F-Ethylcholine Positron Emission Tomography (FEC-PET)

PET scans were performed on a LSO scanner (ECAT ACCEL, Siemens, Erlangen, Germany) by using a multiphase protocol starting with a "cold" transmission scan of the lower pelvis. This was followed by a list mode emission scan with 10 frames à 1 minute starting immediately after the administration of 3.3MBq \[18F\]Fluoroethylcholine chloride (FEC; Eckert \& Ziegler EURO-PET Berlin GmbH) as a bolus through the cubital vein. After a short gap due to computer processing time the whole body scan was performed starting at the upper thoracic aperture down to the proximal femur. Acquisition parameters were 3 minutes emission scan and 2 minutes transmission scan for each bed position. Therefore the prostate region was scanned again at 45 minutes p.i. (post injection) A delayed local acquisition at 65 minutes over the lower pelvis with 6 minutes emission and 2 minutes transmission finished the diagnostic acquisition procedure.

Intervention Type: OTHER

Endorectal Magnetic Resonance Imaging (1.5Tesla) (eMRI)

The MRI examination was performed on a 1.5Tesla MRI system (Gyroscan ACS-NT, Philips, Hamburg, Germany) with combined QBody and endorectal coil. Pelvic assessment and lymph node staging was effected with 5mm T2 weighted (T2w) turbo spin echo (TSE) transversal and a coronal short-tau inversion recovery (STIR) sequence. For prostate assessment, 3mm endorectal T2w spin echo (SE) sagittal, transversal and coronal sequences were acquired.

Intervention Type: OTHER

Eligibility Criteria

Inclusion Criteria

• Histologically diagnosed prostate cancer (needle biopsy)
• Radical prostatectomy as primary treatment
• No nutrition within 12 hours before Positron-Emission-Tomography (PET)
• No food containing choline within 24 hous before PET
• Age > 50 years

Exclusion Criteria

• Total endo-prothesis of the hip region
• Clinical or chemical detection of an acute infection
• Missing patient agreement
• Secondary cancer
• Surgical treatment within 3 month before PET
• Claustrophobia
• Medical drugs with choline
• Severe liver damage
• Cardiac infarction
• Bradycardia (pulse rate < 55/min)
• Allergic reaction against Neurotropan
• Bronchial asthma
• Cardiac pacemaker
• Small metal implants (e.g., clips, cochlea-implants, etc.)

• Minimum Eligible Age: 50 Years
• Eligible Sex: MALE
• Accepts Healthy Volunteers: No

Sponsors

Dr. Markus Hartenbach

OTHER

Sponsor Role: lead

Responsible Party

Dr. Markus Hartenbach

Major Medical Corps and assistant medical director of the nuclear medicine department

Responsibility Role: SPONSOR_INVESTIGATOR

Principal Investigators

Markus Hartenbach, Dr.

Role: PRINCIPAL_INVESTIGATOR

German Federal Armed Forces Hospital, Ulm, Dep. of Nuclear Medicine

Christoph Sparwasser, Prof. Dr.

Role: STUDY_DIRECTOR

German Federal Armed Forces Hospital Ulm, Dep. of Urology

Locations

German Federal Armed Forces Hospital

Ulm, Baden-Wurttemberg, Germany

Countries

Germany

References

Robert-Koch-Institut (2010): Krebs in Deutschland 2005/2006 Häufigkeiten und Trends. A collaborative publication of the Robert-Koch-Institut and the Gesellschaft der epidemiologischen Krebsregister in Deutschland e.V. [Society for epidemiological cancer register], 7th edition, Berlin.

Reference Type: BACKGROUND

Börgermann C, Rübben H (2006): Früherkennung des Prostatakarzinoms [Early recognition of prostate carcinoma]. Dtsch Arztebl. 103: 2399-2406.

Reference Type: BACKGROUND

Breslow N, Chan CW, Dhom G, Drury RA, Franks LM, Gellei B, Lee YS, Lundberg S, Sparke B, Sternby NH, Tulinius H. Latent carcinoma of prostate at autopsy in seven areas. The International Agency for Research on Cancer, Lyons, France. Int J Cancer. 1977 Nov 15;20(5):680-8. doi: 10.1002/ijc.2910200506.

Reference Type: BACKGROUND

PMID: 924691 (View on PubMed)

de Jong IJ, Pruim J, Elsinga PH, Vaalburg W, Mensink HJ. Preoperative staging of pelvic lymph nodes in prostate cancer by 11C-choline PET. J Nucl Med. 2003 Mar;44(3):331-5.

Reference Type: BACKGROUND

PMID: 12620996 (View on PubMed)

Deutsche Gesellschaft für Urologie (2009): Interdisziplinäre Leitlinie der Qualität S3 zur Früherkennung, Diagnose und Therapie der verschiedenen Stadien des Prostatakarzinoms [Interdisciplinary guideline for the early recognition, diagnosis and therapy of the various stages of prostate carcinoma]. Deutsche Gesellschaft für Urologie e. V. (ed.), p. 53 ff.

Reference Type: BACKGROUND

FDA (2011): FDA clears new system to perform simultaneous PET, MRI scans. Available on-line at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2011/ucm258700.htm

Reference Type: BACKGROUND

Gauthier S, Diksic M, Yamamoto L, Tyler J, Feindel WH (1985): Positron emission tomography with [11C]-choline in human subjects. Can J Neurol Sci 12: 214.

Reference Type: BACKGROUND

Hara T, Kosaka N, Shinoura N, Kondo T. PET imaging of brain tumor with [methyl-11C]choline. J Nucl Med. 1997 Jun;38(6):842-7.

Reference Type: BACKGROUND

PMID: 9189127 (View on PubMed)

Hara T, Kosaka N, Kishi H. PET imaging of prostate cancer using carbon-11-choline. J Nucl Med. 1998 Jun;39(6):990-5.

Reference Type: BACKGROUND

PMID: 9627331 (View on PubMed)

Hara T, Kosaka N, Kishi H. Development of (18)F-fluoroethylcholine for cancer imaging with PET: synthesis, biochemistry, and prostate cancer imaging. J Nucl Med. 2002 Feb;43(2):187-99.

Reference Type: BACKGROUND

PMID: 11850483 (View on PubMed)

Kwee SA, Coel MN, Lim J, Ko JP. Prostate cancer localization with 18fluorine fluorocholine positron emission tomography. J Urol. 2005 Jan;173(1):252-5. doi: 10.1097/01.ju.0000142099.80156.85.

Reference Type: BACKGROUND

PMID: 15592091 (View on PubMed)

Pegios W, Bentas W, Wittmann L, Mack MG, Zangos S, Sollner O, Binder J, Fellbaum C, Jonas D, Vogl TJ. [MRI staging of prostate cancer with the combined endorectal body phased-array coil and histologic correlation]. Rofo. 2003 Dec;175(12):1660-6. doi: 10.1055/s-2003-45325. German.

Reference Type: BACKGROUND

PMID: 14661137 (View on PubMed)

Porter CR, Kodama K, Gibbons RP, Correa R Jr, Chun FK, Perrotte P, Karakiewicz PI. 25-year prostate cancer control and survival outcomes: a 40-year radical prostatectomy single institution series. J Urol. 2006 Aug;176(2):569-74. doi: 10.1016/j.juro.2006.03.094.

Reference Type: BACKGROUND

PMID: 16813891 (View on PubMed)

Yamaguchi T, Lee J, Uemura H, Sasaki T, Takahashi N, Oka T, Shizukuishi K, Endou H, Kubota Y, Inoue T. Prostate cancer: a comparative study of 11C-choline PET and MR imaging combined with proton MR spectroscopy. Eur J Nucl Med Mol Imaging. 2005 Jul;32(7):742-8. doi: 10.1007/s00259-004-1755-y. Epub 2005 Mar 15.

Reference Type: BACKGROUND

PMID: 16052370 (View on PubMed)

Other Identifiers

2006-003933-33

Identifier Type: EUDRACT_NUMBER

Identifier Source: secondary_id

12K3-S-140708

Identifier Type: -

Identifier Source: org_study_id