1. Pylarify
   1. Prostate-specific membrane antigen (PSMA-11) is excessively expressed on the surface of prostate cancer cells
   2. In a random study of 300 men metastatic disease was went from 65% to 92% when Pylarify was administered
   3. Any increase in PSA levels of 2 ng/mL is an indication of recurrence
   4. Since Plarify is PSMA specific it appear to be more sensitive when compared to Axumin.
   5. Some of this data is based on ⁶⁸Ga-PMSA-11 noting that Pylarify is tagged to fluorine
   6. Gleason's score of >7, PSA of >20ng/mL, or clinical staging of T2c-3a suggests lymph and bone involvement and may indicate a reason to complete a Plarify study
   7. Dose - 0.05 to 0.06 mCi/kg given as an IV bolus
   8. Scanning may start between 5 - to 100 minutes post dose
      1. Indeterminate diagnosing being repeated up to 3 hours post injection
      2. Start acquisition at mid-thigh to the base of the skull
      
      Link
      3. Example of a normal Illuccix scan
2. Axumin
   1. Is an amino acid-based compound, not PSMA
   2. There is some variation of sensitivity in detecting disease based on the PSA level where patients with prostate cancer that have a lower levels of PSA may go undetected with Axumin. To a lesser extent this may also be true with the PSMA tracers

       

   
   Link
   3. Comparison of PSMA type radiotracer to Axumin. Note PSMA tracer is not tagged to ¹⁸F
   4. According to literature, any PSA level that is 2.0 ng/mL or more above the nadir is an indication of disease recurrence. A level of 0.1 ng/mL or less is considered a level below the nadir value
   5. As Gleason scores increase Axumin becomes more sensitive. This also correlates to increases in the PSA level
      1. Prostate cancer within the bed of the prostate shows sensitivity of 88 to 90% with specificity of 32 to 40%
      2. Disease found outside the prostate bed, sensitivity to continues to increases while specificity falls into the moderate range
      3. Recurrence of disease - sensitivity 55%, specificity 97%, and accuracy 73%
      4. There is a relationship of PSA levels to Axumin uptake, in which the greater the PSA value the greater the sensitivity
      5. These is also coloration of Axumin uptake in metastatic bone disease
   6. Imaging protocol
      1. Patient Prep - No exercise 24 hours prior. NPO 4 to 6 hours before the scan. Patient should attempt not to void 30 to 60 minutes before the scan. Stay well hydrated post scanning.
      2. Dose - 10 mCi and it can be diluted, up to a factor of 8. Administer IV bolus
      3. Raise arms over the head after scanning
      4. Start imaging 3 to 5 minutes post injection and an initial 0 to 5 minute scan of the pelvis is an optional maneuver
      5. Scan from pelvis to eyes/skull pending anatomy
      
      Link
      6. Example of normal distribution
      7. If abnormal uptake is seen in the bone a nuclear medicine bone scan may be suggested

Illuccix Website

Pylarify Website

Axumin Website

Information on this presentation have been acquired through the following resources:

[18F]Fluciclovine PET/CT: joint EANM and SNMMI procedure guideline for prostate cancer imaging—version 1.0 - Link

⁶⁸Ga-PSMA PET/CT: Joint EANM and SNMMI procedure guideline for prostate cancer imaging: version 1.0 - Link