Assessment of Simplified Methods for Quantification of 18F-FDHT Uptake in Patients with Metastatic Castration-Resistant Prostate Cancer.

18F-fluorodihydrotestosterone (18F-FDHT) PET/CT potentially provides a noninvasive method for assessment of androgen receptor expression in patients with metastatic castration-resistant prostate cancer (mCRPC). The objective of this study was to assess simplified methods for quantifying 18F-FDHT uptake in mCRPC patients and to assess effects of tumor perfusion on these 18F-FDHT uptake metrics. Methods: Seventeen mCRPC patients were included in this prospective observational multicenter study. Test and retest 30-min dynamic 18F-FDHT PET/CT scans with venous blood sampling were performed in 14 patients. In addition, arterial blood sampling and dynamic 15O-H2O scans were obtained in a subset of 6 patients. Several simplified methods were assessed: Patlak plots; SUV normalized to body weight (SUVBW), lean body mass (SUVLBM), whole blood (SUVWB), parent plasma activity concentration (SUVPP), area under the parent plasma curve (SUVAUC,PP), and area under the whole-blood input curve (SUVAUC,WB); and SUVBW corrected for sex hormone-binding globulin levels (SUVSHBG). Results were correlated with parameters derived from full pharmacokinetic 18F-FDHT and 15O-H2O. Finally, the repeatability of individual quantitative uptake metrics was assessed. Results: Eighty-seven 18F-FDHT-avid lesions were evaluated. 18F-FDHT uptake was best described by an irreversible 2-tissue-compartment model. Replacing the continuous metabolite-corrected arterial plasma input function with an image-derived input function in combination with venous sample data provided similar Ki results (R2 = 0.98). Patlak Ki and SUVAUC,PP showed an excellent correlation (R2 > 0.9). SUVBW showed a moderate correlation to Ki (R2 = 0.70, presumably due to fast 18F-FDHT metabolism. When calculating SUVSHBG, correlation to Ki improved (R2 = 0.88). The repeatability of full kinetic modeling parameters was inferior to that of simplified methods (repeatability coefficients > 36% vs. < 28%, respectively). 18F-FDHT uptake showed minimal blood flow dependency. Conclusion:18F-FDHT kinetics in mCRPC patients are best described by an irreversible 2-tissue-compartment model with blood volume parameter. SUVAUC,PP showed a near-perfect correlation with the irreversible 2-tissue-compartment model analysis and can be used for accurate quantification of 18F-FDHT uptake in whole-body PET/CT scans. In addition, SUVSHBG could potentially be used as an even simpler method to quantify 18F-FDHT uptake when less complex scanning protocols and accuracy are required.

How to assess background activity: introducing a histogram-based analysis as a first step for accurate one-step PET quantification.

Many common PET segmentation methods for malignant lesions use surrounding background activity as a reference. To date, background has to be measured by drawing a second volume of interest (VOI) in nearby, undiseased tissue. This is time consuming as two VOIs have to be determined for each lesion. The aim of our study was to analyse whether background activity in different organs and body regions could be calculated from the tumour VOI by histogram analyses. The institutional review board waived informed consent for this retrospective study. For each of the following tumour types and areas - head and neck (neck), lung, hepatic metastasis (liver), melanoma (skin), and cervix (pelvis) - 10 consecutive patients with biopsy-proven tumours who underwent (18)F-fluorodeoxyglucose-PET in January 2012 were retrospectively selected. One lesion was selected and two readers drew a cubical VOI around the lesion (VOItumour) and over the background (VOIBG). The mean value of VOIBG was compared with the mode of the histogram, using equivalence testing with an equivalence margin of ±0.5 SUV. Inter-reader agreement was analysed for the mean background, and the mode of the VOItumour histogram was assessed using the concordance correlation coefficient. For both readers, the mode of VOItumour was equivalent to the mean of VOIBG (P<0.0001 for R1 and R2). The inter-reader agreement was almost perfect, with a concordance correlation coefficient of greater than 0.92 for both the mode of VOItumour and the mean of VOIBG. Background activity determined within a tumour VOI using histogram analysis is equivalent to separately measured mean background values, with an almost perfect inter-reader agreement. This could facilitate PET quantification methods based on background values without increasing workload.