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Cancer Prostate Theranostics: A revolution in the Nuclear Medicine fieldMisr Radiology Center, Egypt
Courtesy of Yehia Omar, Director of PET/CT and Theranostics units



Introduction

In recent years, the FDA has approved two groundbreaking tools for the management of prostate cancer patients, offering new hope in both diagnostics and treatment.  The first is 68Gallium-PSMA PET/CT, which received approval in December 2020 (1). This imaging modality provides a highly accurate whole-body diagnostic scan, capable of detecting prostate cancer metastases throughout the body with significantly greater precision compared to traditional standard-of-care exams, such as bone scans combined with CT of the abdomen and pelvis. Its enhanced diagnostic accuracy has led to changes in patient management in a significant number of cases, enabling more targeted and effective treatment plans (2).  

The second innovation is a novel radioactive therapy called Lutetium-PSMA, approved in March 2022 (3). This targeted radiopharmaceutical therapy involves the intravenous administration of Lutetium-PSMA, a compound that selectively binds to prostate-specific membrane antigen (PSMA) expressed on metastatic prostate cancer cells. Once bound, it delivers localized radiation to destroy these cancer cells throughout the body. Results from the VISION trial demonstrated that patients treated with Lutetium-PSMA experienced prolonged survival, improved quality of life, and a significant reduction in cancer- related pain, while maintaining a favorable side effect profile. Additionally, this therapy has expanded treatment options for patients with advanced disease who previously had limited alternatives (4).

This combination of advanced diagnostic imaging and targeted therapy marks a significant leap forward in the personalized management of prostate cancer. 

Fig. 1: Baseline 68Ga-PSMA PET/CT scan
Fig. 1: Baseline 68Ga-PSMA PET/CT scan

Patient History

We present the case of a 74-year-old male patient diagnosed with metastatic, hormone-resistant prostate cancer, a challenging condition with limited treatment options. The patient had a history of undergoing hormonal therapy with Abiraterone, which initially helped manage his disease, but he eventually developed resistance.

Additionally, he underwent chemotherapy with Docetaxel, a standard treatment for advanced prostate cancer, but his disease progressed despite these interventions. His clinical course highlights the complexities of managing hormone-resistant prostate cancer and underscores the need for novel therapeutic approaches to improve outcomes for patients with this aggressive disease.

Pre-Therapy Scan

The patient’s baseline Ga-PSMA PET/CT scan (Fig.1) revealed widespread metastatic involvement, including diffuse lymph nodes and bony lesions, both exhibiting high PSMA uptake. These findings confirmed the patient’s eligibility for targeted radioligand therapy.

Teaching Point 1

The Ga-PSMA PET/CT scan is a comprehensive whole-body imaging modality capable of detecting all sites of prostate cancer deposits in a single examination, including local recurrence, nodal involvement, bony metastases, and visceral deposits.

The Procedure

The patient received two intravenous therapeutic doses of Lutetium-PSMA, administered two months apart as part of his treatment plan for metastatic, hormone-resistant prostate cancer. The images in Fig. 2 illustrate anterior and posterior SPECT views taken 5 hours after the injection of the first dose of Lutetium-PSMA, providing valuable insights into the therapy’s mechanism of action. These images demonstrate excellent tracer accumulation in the tumor cells, highlighting the high affinity of Lutetium-PSMA for PSMA-expressing cancer cells. The distribution of the tracer closely mirrors the tumoral distribution observed in the pre-therapy PSMA-PET/CT scan, confirming effective targeting of metastatic lesions and underscoring the potential of this therapy for precise tumor eradication.

References:

• U.S. Food and Drug Administration. “FDA approves first PSMA-targeted PET imaging drug for men with prostate cancer.” Available at: https://www.fda.gov/news-events/press announcements/fda-approves-first-psma-targeted-pet-imaging-drug-men-prostate-cancer.

• Hofman, Michael S., et al. “Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomized, multicenter study.” Lancet (London, England) 395, no. 10231 (2020): 1208-1216. doi:10.1016/S0140-6736(20)30314-7.

• U.S. Food and Drug Administration. “FDA approves Pluvicto for metastatic castration-resistant prostate cancer.” Available at: https://www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-pluvicto-metastatic-castration-resistant-prostate-cancer.

• Sartor, Oliver, et al. “Lutetium-177-PSMA-617 for metastatic castration-resistant prostate cancer.” The New England Journal of Medicine 385, no. 12 (2021): 1091-1103.doi:10.1056/NEJMoa2107322.

"Lutetium-PSMA is a radioactive therapy used for patients with metastatic prostate cancer. It has been shown to prolong survival, significantly improve quality of life, and is associated with low side effects."
Dr. Yehia Omar
Dr. Yehia Omar
Director of PET/CT and Theranostics units 
Misr Radiology Center, Egypt