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Background
Prostate cancer is a leading cause of cancer-related mortality in men. At least one-third of the patients undergoing treatment experience cancer recurrence. The location and extent of prostate cancer recurrence cannot be accurately assessed utilizing conventional imaging such as computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine bone scintigraphy, or even conventional F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT). Accurate disease staging is important as the presence of extrapelvic metastatic disease typically excludes patients from salvage radiation therapy and necessitates systemic therapy. 18F-Fluciclovine (Anti-1-Amino-3–18F-Fluorocyclobutane-1-Carboxylic Acid [FACBC]) PET/CT is a novel modality that has a much higher sensitivity for the detection and accurate characterization of recurrent prostatic neoplastic disease compared to conventional imaging.

Educational Goals / Teaching Points
Prostate cancer is a leading cause of cancer-related mortality in men with a significant rate of posttreatment recurrence. Accurate staging of recurrent prostate cancer is crucial for appropriate management. Describe the utility of 18F-Fluciclovine PET/CT for the detection of recurrent prostate cancer. Familiarize the audience with the imaging findings of recurrent prostate cancer as seen with 18F-Fluciclovine PET/CT.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
18F-Fluciclovine PET/CT uses a radiolabeled analog of levorotatory leucine (L-Leucine), an essential amino acid, the cellular transporter for which is upregulated in prostate cancer cells, among other normal and malignant tissues (with the highest uptake in tissues that produce proteins or process amino acids). The highest physiologic uptake of FACBC is within the pancreas, followed by the liver (the critical organ), with additional uptake within the pituitary gland, salivary glands, bowel, red marrow, and musculature. Compared to conventional FDG PET/CT, there is little activity within the renal and urinary systems mitigating interferences in imaging interpretation. The diagnostic sensitivity for 18F-Fluciclovine PET/CT correlates with increasing Prostate-Specific Antigen (PSA) levels.

Conclusion
18F-Fluciclovine is a novel PET/CT agent with a much higher sensitivity for the detection and accurate characterization of recurrent prostate cancer compared with conventional imaging. Familiarity with imaging characteristics of 18F-Fluciclovine PET/CT is important for timely and accurate staging and management of recurrent neoplastic disease, especially given its higher efficacy compared with conventional modalities. 18F-Fluciclovine PET/CT may even serve as a prospective agent for initial workup and primary staging for prostate carcinoma.