[18F]fluciclovine vs. [18F]fluorocholine Positron Emission Tomography/Computed Tomography: A Head-to-Head Comparison for Early Detection of Biochemical Recurrence in Prostate Cancer Patients

Nowadays, there is still no consensus on the most accurate PET radiopharmaceutical to early detect prostate cancer (PCa) relapse. A tailored radiotracer choice based on a specific patient's profile could ensure prompt disease detection and an improvement in patients management. We aimed to compare the [F-18]fluciclovine and [F-18]fluorocholine PET/CT detection rate (DR) in PCa patients restaged for early biochemical recurrence (BCR), according to clinical and biochemical features. A cohort of 138 PCa patients with early BCR (mean age: 71 y, range: 50-87 y) were homogeneously randomized 1:1 to a [F-18]fluciclovine or a [F-18]fluorocholine PET/CT group. The respective PET/CT DR, according to per-patient and per-region analysis, and the impact of the biochemical, clinical, and histological parameters, were compared. The PSA cut-off values predictive of a positive scan were also calculated. Overall, the [F-18]fluciclovine PET/CT DR was 64%, significantly higher than the [F-18]fluorocholine PET/CT DR of 35% (p = 0.001). Similarly, in the per-region analysis, the [F-18]fluciclovine PET/CT DR was 51% in the prostate region, significantly higher compared to 15% of [F-18]fluorocholine (p < 0.0001). Furthermore, a statistically significant higher DR in per-patient and per-region (prostate/prostate bed) analysis was observed in the [F-18]fluciclovine group for 0.5-1 ng/mL (p = 0.018, p = 0.049) and >1 ng/mL (p = 0.040, p < 0.0001) PSA values. A PSA of 0.45 ng/mL for [F-18]fluciclovine and of 0.94 ng/mL for [F-18]fluorocholine was identified as the optimal cut-off value in predicting a positive PET/CT scan. Our results demonstrated a better [F-18]fluciclovine PET/CT DR compared to [F-18]fluorocholine for restaging PCa patients in early BCR, particularly in the detection of locoregional recurrence. The significantly higher [F-18]fluciclovine DR for low PSA values (PSA < 1 ng/mL) supports its use in this setting of patients.