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Xiao L, Su M, Li Y. Diagnostic value of dual-time point 68Ga-PSMA PET/CT image for benign and malignant lesions in patients with prostate cancer. Abdom Radiol (NY) 2024; 49:3214-3219. [PMID: 38546825 DOI: 10.1007/s00261-024-04269-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/23/2024] [Accepted: 02/25/2024] [Indexed: 08/22/2024]
Abstract
OBJECTIVE This study aimed to ascertain the diagnostic efficacy of routine 68Ga-PSMA imaging conducted 1 h post-injection, in conjunction with delayed imaging performed 3 h post-injection, for differentiating between benign and malignant lesions in prostate cancer (PCa) patients. METHODS A retrospective assessment was undertaken on 44 prostate cancer patients who had undergone both routine and delayed 68Ga-PSMA PET/CT scans. Variations in SUVmax and SUVmean values in normal organs, primary prostate cancer sites, metastatic sites, and benign lesions were analyzed. Pathological examination and extended follow-ups were used to confirm all lesions. RESULTS The study encompassed 44 patients, presenting 35 primary prostate cancer lesions, 44 metastatic lesions, and 30 benign lesions. Delayed imaging (3 h post-injection) demonstrated a decreasing trend in the SUVmax and SUVmean for the liver, blood, and spleen. Conversely, an increasing trend was observed for the parotid, lacrimal, and submandibular glands. For primary lesions, the SUVmax and SUVmean values were 17.63 ± 9.61 and 9.77 ± 5.18 during routine imaging, and 25.09 ± 15.11 and 14.05 ± 8.02 (P < 0.001) during delayed imaging. A comparable increase in SUVmax and SUVmean was seen in the delayed images for metastatic lesions when juxtaposed with routine images. Nevertheless, benign lesions displayed a decrease in SUVmax and SUVmean during delayed imaging when set against routine imaging (SUVmax: 3.56 ± 1.49 vs 2.93 ± 1.47, P = 0.001; SUVmean: 1.99 ± 0.87 vs 1.65 ± 0.87, P = 0.003). CONCLUSION Imaging using 68Ga-PSMA PET/CT at 3 h post-injection manifested a higher uptake and target-to-background uptake in most malignant prostate cancer lesions, but a diminished uptake in benign lesions. This observation can assist clinicians in distinguishing non-specific PSMA uptake in prostate cancer patients based on PSMA PET/CT image.
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Affiliation(s)
- Liu Xiao
- Department of Nuclear Medicine, West China Hospital of Sichuan University, No. 37. Guoxue Alley, Chengdu, 610041, Sichuan, People's Republic of China
| | - Minggang Su
- Department of Nuclear Medicine, West China Hospital of Sichuan University, No. 37. Guoxue Alley, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yuhao Li
- Department of Nuclear Medicine, West China Hospital of Sichuan University, No. 37. Guoxue Alley, Chengdu, 610041, Sichuan, People's Republic of China.
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Alberts IL, Seifert R, Werner RA, Rowe SP, Afshar-Oromieh A. Prostate-specific Membrane Antigen: Diagnostics. PET Clin 2024; 19:351-362. [PMID: 38702228 DOI: 10.1016/j.cpet.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024]
Abstract
Since its clinical introduction in May 2011, prostate-specific membrane antigen (PSMA)-PET/computed tomography has quickly gained worldwide recognition as a significant breakthrough in prostate cancer diagnostics. In the meantime, several new PSMA radioligands for PET imaging have been introduced into routine clinical practice. This article aims to introduce the most commonly used tracers and their key areas of application.
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Affiliation(s)
- Ian L Alberts
- Molecular Imaging and Therapy, BC Cancer - Vancouver, 600 West 10th Avenue, Vancouver, British Columbia V5Z 1H5, Canada
| | - Robert Seifert
- University Clinic for Nuclear Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Rudolf A Werner
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080 Würzburg, Germany; Division of Nuclear Medicine, Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Goethe University Frankfurt, University Hospital, Germany
| | - Steven P Rowe
- Molecular Imaging and Therapeutics, Department of Radiology, University of North Carolina, Chapel Hill, NC, USA
| | - Ali Afshar-Oromieh
- University Clinic for Nuclear Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland.
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Sachpekidis C, Pan L, Groezinger M, Strauss DS, Dimitrakopoulou-Strauss A. Combined whole-body dynamic and static PET/CT with low-dose [ 18F]PSMA-1007 in prostate cancer patients. Eur J Nucl Med Mol Imaging 2024; 51:2137-2150. [PMID: 38286936 PMCID: PMC11139746 DOI: 10.1007/s00259-024-06620-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/17/2024] [Indexed: 01/31/2024]
Abstract
AIM In addition to significant improvements in sensitivity and image quality, the recent introduction of long axial field-of-view (LAFOV) PET/CT scanners has enabled dynamic whole-body imaging for the first time. We aim herein to determine an appropriate acquisition time range for static low-dose [18F]PSMA-1007 PET imaging and to investigate the whole-body pharmacokinetics of [18F]PSMA-1007 by dynamic PET with the LAFOV Biograph Vision Quadra PET/CT in a group of prostate cancer patients. METHODOLOGY In total, 38 prostate cancer patients were enrolled in the analysis for staging or re-staging purposes. Thirty-four patients underwent dynamic whole-body PET/CT (60 min) followed by static whole-body PET/CT and four patients underwent static whole-body PET/CT only. The activity applied was 2 MBq/kg [18F]PSMA-1007. The static PET images of 10-min duration (PET-10) were reconstructed and further split into 8-min (PET-8), 6-min (PET-6), 5-min (PET-5), 4-min (PET-4), and 2-min (PET-2) duration groups. Comparisons were made between the different reconstructed scan times in terms of lesion detection rate and image quality based on SUV calculations of tumor lesions and the spleen, which served as background. Analysis of the dynamic PET/CT data was based on a two-tissue compartment model using an image-derived input function obtained from the descending aorta. RESULTS Analysis of lesion detection rate showed no significant differences when reducing PET acquisitions from 10 up to 5 min. In particular, a total of 169 lesions were counted with PET-10, and the corresponding lesion detection rates (95% CI for the 90% quantile of the differences in tumor lesions) for shorter acquisitions were 100% (169/169) for PET-8 (95% CI: 0-0), 98.8% (167/169) for PET-6 (95% CI: 0-1), 95.9% (162/169) for PET-5 (95% CI: 0-3), 91.7% (155/169) for PET-4 (95% CI: 1-2), and 85.2% (144/169) for PET-2 (95% CI: 1-6). With the exception of PET-2, the differences observed between PET-10 and the other shorter acquisition protocols would have no impact on any patient in terms of clinical management. Objective evaluation of PET/CT image quality showed no significant decrease in tumor-to-background ratio (TBR) with shorter acquisition times, despite a gradual decrease in signal-to-noise ratio (SNR) in the spleen. Whole-body quantitative [18F]PSMA-1007 pharmacokinetic analysis acquired with full dynamic PET scanning was feasible in all patients. Two-tissue compartment modeling revealed significantly higher values for the parameter k3 in tumor lesions and parotid gland compared to liver and spleen, reflecting a higher specific tracer binding to the PSMA molecule and internalization rate in these tissues, a finding also supported by the respective time-activity curves. Furthermore, correlation analysis demonstrated a significantly strong positive correlation (r = 0.72) between SUV and k3 in tumor lesions. CONCLUSIONS In prostate cancer, low-dose (2 MBq/kg) [18F]PSMA-1007 LAFOV PET/CT can reduce static scan time by 50% without significantly compromising lesion detection rate and objective image quality. In addition, dynamic PET can elucidate molecular pathways related to the physiology of [18F]PSMA-1007 in both tumor lesions and normal organs at the whole-body level. These findings unfold many of the potentials of the new LAFOV PET/CT technology in the field of PSMA-based diagnosis and theranostics of prostate cancer.
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Affiliation(s)
- Christos Sachpekidis
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, D-69210, Heidelberg, Germany.
| | - Leyun Pan
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, D-69210, Heidelberg, Germany
| | - Martin Groezinger
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, D-69210, Heidelberg, Germany
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Dimitrios Stefanos Strauss
- Department of Diagnostic and Interventional Radiology (DIR), Heidelberg University Hospital, Heidelberg, Germany
| | - Antonia Dimitrakopoulou-Strauss
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, D-69210, Heidelberg, Germany
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Sachpekidis C, Dimitrakopoulou-Strauss A. Long Axial Field-of-View (LAFOV) PET/CT in Prostate Cancer. Semin Nucl Med 2024:S0001-2998(24)00045-X. [PMID: 38825439 DOI: 10.1053/j.semnuclmed.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 05/16/2024] [Indexed: 06/04/2024]
Abstract
PSMA-targeted PET/CT is currently considered the most effective non-invasive diagnostic technique for imaging PSMA-positive lesions in prostate cancer (PC), and its introduction has significantly enhanced the role of nuclear medicine in both the diagnosis and therapy (theranostics) of this oncological entity. In line with developments in radiopharmaceuticals, significant progress has been made in the development of PET/CT systems. In particular, the advent of long axial field-of-view (LAFOV) PET/CT scanners has represented a major leap forward in molecular imaging, with early results from clinical applications of these systems showing significant improvements over previous standard axial field-of-view systems in terms of sensitivity, image quality and lesion quantification, while enabling whole-body dynamic PET imaging. In this context, the introduction of the new LAFOV scanners may further enhance the use and potential of PSMA-ligand PET/CT in the diagnosis and management of PC. The initial but steadily growing literature on the application of the new technology in the field of PSMA-ligand PET/CT has already yielded encouraging results regarding the detection of PC lesions with high sensitivity while providing the possibility of ultra-fast or ultra-low dose examinations. Moreover, whole-body dynamic PET has rendered for the first time feasible to capture the pharmacokinetics PSMA-ligands in all major organs and most tumor lesions with high temporal resolution. The main results of these studies are presented in this review.
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Affiliation(s)
- Christos Sachpekidis
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Donswijk ML, Ettema RH, Meijer D, Wondergem M, Cheung Z, Bekers EM, van Leeuwen PJ, van den Bergh RCN, van der Poel HG, Vis AN, Oprea-Lager DE. The accuracy and intra- and interobserver variability of PSMA PET/CT for the local staging of primary prostate cancer. Eur J Nucl Med Mol Imaging 2024; 51:1741-1752. [PMID: 38273003 PMCID: PMC11043118 DOI: 10.1007/s00259-024-06594-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/02/2024] [Indexed: 01/27/2024]
Abstract
PURPOSE Prostate-specific membrane antigen (PSMA) positron emission tomography/ computed tomography (PET/CT) is recognized as the most accurate imaging modality for detection of metastatic high-risk prostate cancer (PCa). Its role in the local staging of disease is yet unclear. We assessed the intra- and interobserver variability, as well as the diagnostic accuracy of the PSMA PET/CT based molecular imaging local tumour stage (miT-stage) for the local tumour stage assessment in a large, multicentre cohort of patients with intermediate and high-risk primary PCa, with the radical prostatectomy specimen (pT-stage) serving as the reference standard. METHODS A total of 600 patients who underwent staging PSMA PET/CT before robot-assisted radical prostatectomy was studied. In 579 PSMA positive primary prostate tumours a comparison was made between miT-stage as assessed by four nuclear physicians and the pT-stage according to ISUP protocol. Sensitivity, specificity and diagnostic accuracy were determined. In a representative subset of 100 patients, the intra-and interobserver variability were assessed using Kappa-estimates. RESULTS The sensitivity and specificity of the PSMA PET/CT based miT-stage were 58% and 59% for pT3a-stage, 30% and 97% for ≥ pT3b-stage, and 68% and 61% for overall ≥ pT3-stage, respectively. No statistically significant differences in diagnostic accuracy were found between tracers. We found a substantial intra-observer agreement for PSMA PET/CT assessment of ≥ T3-stage (k 0.70) and ≥ T3b-stage (k 0.75), whereas the interobserver agreement for the assessment of ≥ T3-stage (k 0.47) and ≥ T3b-stage (k 0.41) were moderate. CONCLUSION In a large, multicentre study evaluating 600 patients with newly diagnosed intermediate and high-risk PCa, we showed that PSMA PET/CT may have a value in local tumour staging when pathological tumour stage in the radical prostatectomy specimen was used as the reference standard. The intra-observer and interobserver variability of assessment of tumour extent on PSMA PET/CT was moderate to substantial.
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Affiliation(s)
- Maarten L Donswijk
- Department of Nuclear Medicine, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
| | - Rosemarijn H Ettema
- Department of Urology, Amsterdam University Medical Centres, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Prostate cancer network, Amsterdam, The Netherlands
- Department of Urology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Dennie Meijer
- Department of Urology, Amsterdam University Medical Centres, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Prostate cancer network, Amsterdam, The Netherlands
| | - Maurits Wondergem
- Department of Nuclear Medicine, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Zing Cheung
- Department of Nuclear Medicine, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Elise M Bekers
- Department of Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Pim J van Leeuwen
- Prostate cancer network, Amsterdam, The Netherlands
- Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | | | - Henk G van der Poel
- Department of Urology, Amsterdam University Medical Centres, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Prostate cancer network, Amsterdam, The Netherlands
- Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - André N Vis
- Department of Urology, Amsterdam University Medical Centres, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Prostate cancer network, Amsterdam, The Netherlands
| | - Daniela E Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Raju S, Sharma A, Kumar S, Seth A, Sharma A, Pandey AK, Kumar R. Impact of forced diuresis at two different time points on pelvic imaging in prostatic carcinoma with 68 Ga-PSMA PET/CT. Nucl Med Commun 2023; 44:1135-1143. [PMID: 37799105 DOI: 10.1097/mnm.0000000000001771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
OBJECTIVE We compared diagnostic quality of 68 Ga-PSMA PET/CT imaging focused on the pelvic structures using two furosemide protocols in two different groups of patients. MATERIAL AND METHODS A total of 55 patients with prostate cancer were retrospectively enrolled in the study. Out of 55, 31 patients were in group 1 (median age: 66 years, Range 44-78 years) in which furosemide injection was given after completion of whole-body 68 Ga-PSMA PET/CT scan and 24 patients were in group 2 (median age: 63.5 years, range: 50-82 years) in which it was given along with the 68 Ga-PSMA injection. In both groups, an initial time point scan (T0 scan) and a delayed time point scan (T1scan) were done. The images were analyzed qualitatively as well as quantitatively. RESULTS Quantitatively there was no statistically significant difference between the SUVmax and T:B of prostatic lesion and seminal vesicle invasion (SVI) in both the groups at two time points ( P > 0.05). Early furosemide injection caused a washout of the urinary bladder radiotracer concentration in significantly higher number of patients in group 2 (62.5% vs. 6.45% patients, P < 0.001). There was significant clearance of radiotracer activity from the ureters in group 2 (SUVmax: 9.28 vs. 3.09, P = 0.002). CONCLUSION The simultaneous furosemide and 68 Ga-PSMA injection can reduce the urinary excretion of the tracer and improve the diagnostic confidence of prostatic lesion, SVI and lymph nodal metastasis, along with reducing the scanning time and radiation burden, making this protocol an effective alternative to the present protocol of delayed furosemide injection.
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Affiliation(s)
| | | | | | | | | | | | - Rakesh Kumar
- Diagnostic Nuclear Medicine Division, Department of Nuclear Medicine, AIIMS, New Delhi, India
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Dias AH, Jochumsen MR, Zacho HD, Munk OL, Gormsen LC. Multiparametric dynamic whole-body PSMA PET/CT using [ 68Ga]Ga-PSMA-11 and [ 18F]PSMA-1007. EJNMMI Res 2023; 13:31. [PMID: 37060394 PMCID: PMC10105814 DOI: 10.1186/s13550-023-00981-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/31/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Routine prostate-specific membrane antigen (PSMA) positron emission tomography (PET) performed for primary staging or restaging of prostate cancer patients is usually done as a single static image acquisition 60 min after tracer administration. In this study, we employ dynamic whole-body (D-WB) PET imaging to compare the pharmacokinetics of [68Ga]Ga-PSMA-11 and [18F]PSMA-1007 in various tissues and lesions, and to assess whether Patlak parametric images are quantitative and improve lesion detection and image readability. METHODS Twenty male patients with prostate cancer were examined using a D-WB PSMA PET protocol. Ten patients were scanned with [68Ga]Ga-PSMA-11 and ten with [18F]PSMA-1007. Kinetic analyses were made using time-activity curves (TACs) extracted from organs (liver, spleen, bone, and muscle) and lesions. For each patient, three images were produced: SUV + Patlak parametric images (Ki and DV). All images were reviewed visually to compare lesion detection, image readability was quantified using target-to-background ratios (TBR), and Ki and DV values were compared. RESULTS The two PSMA tracers exhibited markedly different pharmacokinetics in organs: reversible for [68Ga]Ga-PSMA-11 and irreversible for [18F]PSMA-1007. For both tracers, lesions kinetics were best described by an irreversible model. All parametric images were of good visual quality using both radiotracers. In general, Ki images were characterized by reduced vascular signal and increased lesion TBR compared with SUV images. No additional malignant lesions were identified on the parametric images. CONCLUSION D-WB PET/CT is feasible for both PSMA tracers allowing for direct reconstruction of parametric Ki images. The use of multiparametric PSMA images increased TBR but did not lead to the detection of more lesions. For quantitative whole-body Ki imaging, [18F]PSMA-1007 should be preferred over [68Ga]Ga-PSMA-11 due to its irreversible kinetics in organs and lesions.
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Affiliation(s)
- André H Dias
- Department of Nuclear Medicine & PET Centre, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N, Denmark.
| | - Mads R Jochumsen
- Department of Nuclear Medicine & PET Centre, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Helle D Zacho
- Department of Nuclear Medicine and Clinical Cancer Research Centre, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ole L Munk
- Department of Nuclear Medicine & PET Centre, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lars C Gormsen
- Department of Nuclear Medicine & PET Centre, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Duncan I, Ingold N, Martinez-Marroquin E, Paterson C. An Australian experience using Tc-PSMA SPECT/CT in the primary diagnosis of prostate cancer and for staging at biochemical recurrence after local therapy. Prostate 2023; 83:970-979. [PMID: 37051636 DOI: 10.1002/pros.24538] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 03/03/2023] [Accepted: 04/03/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Technetium 99 prostate-specific membrane antigen (Tc-PSMA) single-photon emission computed tomography/computed tomography (SPECT/CT) has the potential to provide greater accessibility globally than gallium 68 (Ga)-PSMA positron emission tomography (PET)/CT but has not been studied as extensively in primary diagnosis, staging, or relapse of prostate cancer (PC). We instituted a novel SPECT/CT reconstruction algorithm using Tc-PSMA and established a database to prospectively accumulate data on all patients referred with PC. This study extracts data on all patients referred over a 3.5-year period with the primary aim of comparing the diagnostic accuracy of Tc-PSMA and multiparametric magnetic resonance imaging (mpMRI) in the primary diagnosis of PC. The secondary aim was to assess the sensitivity of Tc-PSMA in detecting disease with relapse after either radical prostatectomy or primary radiotherapy. METHODS A total of 425 men referred for primary staging (PS) of PC and 172 men referred with biochemical relapse (BCR) were evaluated. We evaluated diagnostic accuracy and correlations between Tc-PSMA SPECT/CT, magnetic resonance imaging (MRI), prostate biopsy, prostate-specific antigen (PSA), and age in the PS group and positivity rates at different PSA levels in the BCR group. RESULTS Taking the biopsy's grade according to the International Society of Urological Pathology protocol as a reference, the sensitivity (true positive rate), specificity (true negative rate), accuracy (positive and negative predictive value), and precision (positive predictive value) for Tc-PSMA in the PS group were 99.7%, 83.3%, 99.4%, and 99.7%, respectively. Comparison rates for MRI in this group were 96.4%, 71.4%, 95.7%, and 99.1%. We found moderate correlations between Tc-PSMA uptake in the prostate and biopsy grade, the presence of metastases, and PSA. In BCR, the Tc-PSMA positive rates were 38.9%, 53.2%, 62.5%, and 84.6% at PSA levels of <0.2, 0.2 to <0.5, 0.5 to <1.0, and > 1.0 ng/mL respectively. CONCLUSIONS We have shown that Tc-PSMA SPECT/CT using an enhanced reconstruction algorithm has a diagnostic performance similar to Ga-PSMA PET/CT and mpMRI in an everyday clinical setting. It may have some advantages in cost, sensitivity for primary lesion detection, and the ability for intraoperative localization of lymph nodes.
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Affiliation(s)
- Iain Duncan
- Garran Medical Imaging, Garran, Australian Capital Territory, Australia
| | - Nicholas Ingold
- Garran Medical Imaging, Garran, Australian Capital Territory, Australia
| | | | - Catherine Paterson
- University of Canberra, Canberra, Australian Capital Territory, Australia
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Xu Y, Klyuzhin I, Harsini S, Ortiz A, Zhang S, Bénard F, Dodhia R, Uribe CF, Rahmim A, Lavista Ferres J. Automatic segmentation of prostate cancer metastases in PSMA PET/CT images using deep neural networks with weighted batch-wise dice loss. Comput Biol Med 2023; 158:106882. [PMID: 37037147 DOI: 10.1016/j.compbiomed.2023.106882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 03/05/2023] [Accepted: 03/30/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE Automatic and accurate segmentation of lesions in images of metastatic castration-resistant prostate cancer has the potential to enable personalized radiopharmaceutical therapy and advanced treatment response monitoring. The aim of this study is to develop a convolutional neural networks-based framework for fully-automated detection and segmentation of metastatic prostate cancer lesions in whole-body PET/CT images. METHODS 525 whole-body PET/CT images of patients with metastatic prostate cancer were available for the study, acquired with the [18F]DCFPyL radiotracer that targets prostate-specific membrane antigen (PSMA). U-Net (1)-based convolutional neural networks (CNNs) were trained to identify lesions on paired axial PET/CT slices. Baseline models were trained using batch-wise dice loss, as well as the proposed weighted batch-wise dice loss (wDice), and the lesion detection performance was quantified, with a particular emphasis on lesion size, intensity, and location. We used 418 images for model training, 30 for model validation, and 77 for model testing. In addition, we allowed our model to take n = 0,2, …, 12 neighboring axial slices to examine how incorporating greater amounts of 3D context influences model performance. We selected the optimal number of neighboring axial slices that maximized the detection rate on the 30 validation images, and trained five neural networks with different architectures. RESULTS Model performance was evaluated using the detection rate, Dice similarity coefficient (DSC) and sensitivity. We found that the proposed wDice loss significantly improved the lesion detection rate, lesion-wise DSC and lesion-wise sensitivity compared to the baseline, with corresponding average increases of 0.07 (p-value = 0.01), 0.03 (p-value = 0.01) and 0.04 (p-value = 0.01), respectively. The inclusion of the first two neighboring axial slices in the input likewise increased the detection rate by 0.17, lesion-wise DSC by 0.05, and lesion-wise mean sensitivity by 0.16. However, there was a minimal effect from including more distant neighboring slices. We ultimately chose to use a number of neighboring slices equal to 2 and the wDice loss function to train our final model. To evaluate the model's performance, we trained three models using identical hyperparameters on three different data splits. The results showed that, on average, the model was able to detect 80% of all testing lesions, with a detection rate of 93% for lesions with maximum standardized uptake values (SUVmax) greater than 5.0. In addition, the average median lesion-wise DSC was 0.51 and 0.60 for all the lesions and lesions with SUVmax>5.0, respectively, on the testing set. Four additional neural networks with different architectures were trained, and they both yielded stronger performance of segmenting lesions whose SUVmax>5.0 compared to the rest of lesions. CONCLUSION Our results demonstrate that prostate cancer metastases in PSMA PET/CT images can be detected and segmented using CNNs. The segmentation performance strongly depends on the intensity, size, and the location of lesions, and can be improved by using specialized loss functions. Specifically, the models performed best in detection of lesions with SUVmax>5.0. Another challenge was to accurately segment lesions close to the bladder. Future work will focus on improving the detection of lesions with lower SUV values by designing custom loss functions that take into account the lesion intensity, using additional data augmentation techniques, and reducing the number of false lesions by developing methods to better separate signal from noise.
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Affiliation(s)
- Yixi Xu
- Microsoft, Redmond, WA, USA.
| | - Ivan Klyuzhin
- Microsoft, Redmond, WA, USA; Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada; Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | | | - Carlos F Uribe
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada; Functional Imaging, BC Cancer, Vancouver, BC, Canada
| | - Arman Rahmim
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada; Department of Radiology, University of British Columbia, Vancouver, BC, Canada
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10
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Mask R-CNN assisted 2.5D object detection pipeline of 68Ga-PSMA-11 PET/CT-positive metastatic pelvic lymph node after radical prostatectomy from solely CT imaging. Sci Rep 2023; 13:1696. [PMID: 36717727 PMCID: PMC9886937 DOI: 10.1038/s41598-023-28669-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 01/23/2023] [Indexed: 02/01/2023] Open
Abstract
Prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) is a molecular and functional imaging modality with better restaging accuracy over conventional imaging for detecting prostate cancer in men suspected of lymph node (LN) progression after definitive therapy. However, the availability of PSMA PET/CT is limited in both low-resource settings and for repeating imaging surveillance. In contrast, CT is widely available, cost-effective, and routinely performed as part of patient follow-up or radiotherapy workflow. Compared with the molecular activities, the morphological and texture changes of subclinical LNs in CT are subtle, making manual detection of positive LNs infeasible. Instead, we harness the power of artificial intelligence for automated LN detection on CT. We examined 68Ga-PSMA-11 PET/CT images from 88 patients (including 739 PSMA PET/CT-positive pelvic LNs) who experienced a biochemical recurrence after radical prostatectomy and presented for salvage radiotherapy with prostate-specific antigen < 1 ng/mL. Scans were divided into a training set (nPatient = 52, nNode = 400), a validation set (nPatient = 18, nNode = 143), and a test set (nPatient = 18, nNodes = 196). Using PSMA PET/CT as the ground truth and consensus pelvic LN clinical target volumes as search regions, a 2.5-dimensional (2.5D) Mask R-CNN based object detection framework was trained. The entire framework contained whole slice imaging pretraining, masked-out region fine-tuning, prediction post-processing, and "window bagging". Following an additional preprocessing step-pelvic LN clinical target volume extraction, our pipeline located positive pelvic LNs solely based on CT scans. Our pipeline could achieve a sensitivity of 83.351%, specificity of 58.621% out of 196 positive pelvic LNs from 18 patients in the test set, of which most of the false positives can be post-removable by radiologists. Our tool may aid CT-based detection of pelvic LN metastasis and triage patients most unlikely to benefit from the PSMA PET/CT scan.
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Glemser PA, Rotkopf LT, Ziener CH, Beuthien-Baumann B, Weru V, Kopp-Schneider A, Schlemmer HP, Dimitrakopoulou-Strauss A, Sachpekidis C. Hybrid imaging with [ 68Ga]PSMA-11 PET-CT and PET-MRI in biochemically recurrent prostate cancer. Cancer Imaging 2022; 22:53. [PMID: 36138437 PMCID: PMC9502876 DOI: 10.1186/s40644-022-00489-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/06/2022] [Indexed: 11/10/2022] Open
Abstract
AIM To compare [68Ga]PSMA-11 PET-CT, [68Ga]PSMA-11 PET-MRI and MRI in a cohort of prostate cancer (PCa) patients in biochemical recurrence after initial curative therapy. MATERIALS AND METHODS Fifty-three patients with biochemically recurrent PCa underwent whole-body [68Ga]PSMA-11 PET-CT 1 hour post-injection (p.i.) followed by [68Ga]PSMA-11 PET-MRI 2.5 hours p.i., including a multiparametric MRI pelvic protocol examination. Imaging data analysis consisted of visual (qualitative) evaluation of the PET-CT, PET-MRI and MRI scans, as well as semi-quantitative and quantitative analyses of the PET and MRI data, including calculation of the parameters standardized uptake value (SUV) and apparent diffusion coefficient (ADC) derived from the PCa lesions. Association analysis was performed between imaging and clinical data, including PSA level and Gleason score. The results were considered significant for p-values less than 0.05 (p < 0.05). RESULTS The hybrid imaging modalities [68Ga]PSMA-11 PET-CT and PET-MRI were positive in more patients than MRI alone. In particular, PET-CT detected lesions suggestive of PCa relapse in 34/53 (64.2%), PET-MRI in 36/53 (67.9%) and MRI in 23/53 patients (43.4%). While no significant differences in lesion detection rate were observed between PET-CT and PET-MRI, the latter was particularly efficient in detection of local recurrences in the prostate bed mainly due to the contribution of the MRI part of the modality. Association analysis revealed a statistically significant increase in the probability of a positive scan with increasing PSA levels for all imaging modalities. Accordingly, there was no significant association between scan positivity rate and Gleason score for any imaging modality. No significant correlation was observed between SUV and ADC values in lymph node metastases. CONCLUSION [68Ga]PSMA-11 PET-CT and PET-MRI provide equally good detection rates for PCa recurrence, both outperforming stand-alone MRI.
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Affiliation(s)
- P A Glemser
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - L T Rotkopf
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Medical Faculty, Ruprecht-Karls-University Heidelberg, 69120, Heidelberg, Germany
| | - C H Ziener
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - B Beuthien-Baumann
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - V Weru
- Department of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - A Kopp-Schneider
- Department of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - H P Schlemmer
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - A Dimitrakopoulou-Strauss
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69210, Heidelberg, Germany
| | - C Sachpekidis
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69210, Heidelberg, Germany.
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12
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Alberts I, Bütikofer L, Rominger A, Afshar-Oromieh A. A randomised, prospective and head-to-head comparison of [68Ga]Ga-PSMA-11 and [18F]PSMA-1007 for the detection of recurrent prostate cancer in PSMA-ligand PET/CT-Protocol design and rationale. PLoS One 2022; 17:e0270269. [PMID: 35853017 PMCID: PMC9295986 DOI: 10.1371/journal.pone.0270269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/09/2022] [Indexed: 12/03/2022] Open
Abstract
Background A number of radiopharmaceuticals are available for the detection of recurrent prostate cancer (rPC), but few comparative imaging trials have been performed comparing them. In particular, there are no prospective head-to-head comparisons of the recently introduced [18F]PSMA-1007 to the existing standard of care [68Ga]Ga-PSMA-11. The purpose of this trial is to establish the non-inferiority of the new radiopharmaceutical in terms of the rate of PET-positive findings and to obtain an intra-individual comparison of accuracy and radiopharmaceutical kinetics. Methods In this cross-over trial we will randomise 100 individuals to receive either first a standard-of-care PET/CT using [68Ga]Ga-PSMA-11 followed by an additional [18F]PSMA-1007 PET/CT within 2 weeks, or vice-versa. Inclusion criteria include patients 18 years and older with biochemical recurrence of prostate cancer following radical prostatectomy, defined as two consecutive prostate specific antigen (PSA) levels > 0.2 ng/ml. Detection rate at the patient-based level is the primary end-point. Each scan will be interpreted by a panel of six independent and masked readers (three for [68Ga]Ga-PSMA-11 and three for [18F]PSMA-1007) which consensus majority in cases of discrepancy. To confirm the PET-positivity rate at a patient based level, follow up at 6 months following the first scan will be performed to a composite standard of truth. Secondary endpoints shall include an intra-individual comparison of radiopharmaceutical-kinetics, per-region detection rate and positive predictive value. Discussion This is the first randomised prospective comparative imaging trial to compare the established [68Ga]Ga-PSMA-11 with [18F]PSMA-1007 and will determine whether the new radiopharmaceutical is non-inferior to the established standard-of-care in terms of patient-level detection rate. Clinical trial registration Registered with and approved by the regional ethics authority #2020–02903 (submitted 09.12.2020, approval 16.12.2021) and the regulatory authority SwissMedic 2020DR2103. Registered with ClinicalTrials.gov Identifier NCT05079828 and additionally in a national language in the Swiss National Clinical Trials Portal (SNCTP).
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Affiliation(s)
- Ian Alberts
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
| | | | - Axel Rominger
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ali Afshar-Oromieh
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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13
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Patient preparation for PET studies. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00043-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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14
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Ong JS, Hofman MS. PET imaging of prostate cancer. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00111-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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15
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Arnfield EG, Thomas PA, Roberts MJ, Pelecanos AM, Ramsay SC, Lin CY, Latter MJ, Garcia PL, Pattison DA. Clinical insignificance of [ 18F]PSMA-1007 avid non-specific bone lesions: a retrospective evaluation. Eur J Nucl Med Mol Imaging 2021; 48:4495-4507. [PMID: 34136957 DOI: 10.1007/s00259-021-05456-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/07/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE [18F]PSMA-1007 offers advantages of low urinary tracer excretion and theoretical improved spatial resolution for imaging prostate cancer. However, non-specific bone lesions (NSBLs), defined as mild to moderate focal bone uptake without a typical morphological correlate on CT, are a common finding on [18F]PSMA-1007 PET/CT. The purpose of this study was to investigate the clinical outcomes of patients with [18F]PSMA-1007 avid NSBLs, to determine whether patients with NSBLs represent a higher risk clinical cohort, and to determine whether SUVmax can be used as a classifier of bone metastasis. METHODS A retrospective audit of 214 men with prostate cancer was performed to investigate the clinical outcomes of [18F]PSMA-1007 avid NSBLs according to defined criteria. We also compared the serum PSA, Gleason score, and uptake time of patients with [18F]PSMA-1007 avid NSBLs to patients without [18F]PSMA-1007 avid bone lesions. Finally, we analysed an SUVmax threshold to identify bone metastases using ROC curve analysis. RESULTS Ninety-four of 214 patients (43.9%) demonstrated at least one NSBL. No [18F]PSMA-1007 avid NSBLs met criteria for a likely malignant or definitely malignant lesion after a median 15.8-month follow-up interval (11.9% definitely benign, 50.3% likely benign, and 37.7% equivocal). There were no statistically significant differences in serum PSA, Gleason score, and uptake time between patients with [18F]PSMA-1007 avid NSBLs and those without [18F]PSMA-1007 avid bone lesions. All NSBLs with adequate follow-up had SUVmax ≤ 11.1. The value of the highest SUVmax distinguished between NSBLs and definite prostate cancer bone metastases, whereby an SUVmax threshold of ≥ 7.2 maximized the Youden's index. CONCLUSION [18F]PSMA-1007 avid NSBLs rarely represent prostate cancer bone metastases. When identified in the absence of definite metastatic disease elsewhere, it is appropriate to classify those with SUVmax < 7.2 as likely benign. NSBLs with SUVmax 7.2-11.1 may be classified as equivocal or metastatic, with patient clinical risk factors, scan appearance, and potential management implications used to guide interpretation.
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Affiliation(s)
- Evyn G Arnfield
- Department of Nuclear Medicine & Specialised PET Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Australia.
| | - Paul A Thomas
- Department of Nuclear Medicine & Specialised PET Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Matthew J Roberts
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Department of Urology, Redcliffe Hospital, Redcliffe, Australia
- Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Anita M Pelecanos
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Stuart C Ramsay
- Department of Nuclear Medicine & Specialised PET Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Medicine, James Cook University, Townsville, Australia
| | - Charles Y Lin
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Radiation Oncology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Melissa J Latter
- Department of Nuclear Medicine & Specialised PET Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Peter L Garcia
- Department of Nuclear Medicine & Specialised PET Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - David A Pattison
- Department of Nuclear Medicine & Specialised PET Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
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Uprimny C, Bayerschmidt S, Kroiss AS, Fritz J, Nilica B, Svirydenka H, Decristoforo C, von Guggenberg E, Horninger W, Virgolini IJ. Early Injection of Furosemide Increases Detection Rate of Local Recurrence in Prostate Cancer Patients with Biochemical Recurrence Referred for 68Ga-PSMA-11 PET/CT. J Nucl Med 2021; 62:1550-1557. [PMID: 33712533 PMCID: PMC8612314 DOI: 10.2967/jnumed.120.261866] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/01/2021] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was twofold. First, we aimed to assess the impact of forced diuresis with early furosemide injection on the detection rate of local recurrence in prostate cancer patients with biochemical recurrence referred for 68Ga-labeled Glu-NH-CO-NH-Lys(Ahx)-HBED-CC (68Ga-PSMA-11) PET/CT. Second, we determined whether intravenous administration of furosemide shortly after tracer injection increases renal washout of 68Ga-PSMA-11 before it binds to the PSMA receptor with possible influence on biodistribution and intensity of tracer uptake in organs with physiologic tracer accumulation. Methods: In a retrospective analysis, 2 different groups with 220 prostate cancer patients each, referred for 68Ga-PSMA-11 PET/CT because of biochemical recurrence after primary therapy, were compared: patients in group 1 (median prostate-specific antigen, 1.30 ng/mL) received no preparation before imaging, whereas patients in group 2 (median prostate-specific antigen, 0.82 ng/mL) were injected with 20 mg of furosemide and 500 mL of sodium chloride (NaCl 0.9%) immediately after tracer injection. The presence of local recurrence was assessed visually. In addition, the intensity of tracer accumulation in organs with physiologic tracer uptake was evaluated. Results: The detection rate of lesions judged positive for local recurrence was significantly higher in patients receiving furosemide than in patients without preparation: 56 cases (25.5%) versus 38 cases (17.3%), respectively (P = 0.048). Median maximum SUVs (SUVmax) of organs with physiologic uptake of 68Ga-PSMA-11 in groups 1 and 2 were urinary bladder (63.0 vs. 8.9), kidney (55.6 vs. 54.5), liver (9.9 vs. 9.4), spleen (11.2 vs. 11.9), small bowel (16.2 vs. 17.1), parotid gland (19.2 vs. 19.6), lacrimal gland (8.9 vs. 10.9), blood-pool activity (2.2 vs. 2.3), muscle (1.0 vs. 1.1), and bone (1.6 vs. 1.6). Apart from bladder activity, no significant reduction of tracer accumulation was found in the patient group receiving furosemide. Conclusion: Injection of 20 mg of furosemide at the time point of radiotracer administration significantly increases the detection rate of local recurrence in prostate cancer patients with biochemical recurrence referred for 68Ga-PSMA-11 PET/CT. As intensity of 68Ga-PSMA-11 uptake in organs with physiologic uptake is not significantly reduced, a negative impact of early furosemide injection on targeting properties and biodistribution of 68Ga-PSMA-11 seems unlikely.
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Affiliation(s)
- Christian Uprimny
- Department of Nuclear Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Steffen Bayerschmidt
- Department of Nuclear Medicine, Medical University Innsbruck, Innsbruck, Austria;
| | | | - Josef Fritz
- Department of Medical Statistics, Informatics and Health Economics, Medical University Innsbruck, Innsbruck, Austria; and
| | - Bernhard Nilica
- Department of Nuclear Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Hanna Svirydenka
- Department of Nuclear Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Clemens Decristoforo
- Department of Nuclear Medicine, Medical University Innsbruck, Innsbruck, Austria
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Alberts I, Niklas-Hünermund J, Sachpekidis C, Zacho HD, Mingels C, Dijkstra L, Bohn KP, Läppchen T, Gourni E, Rominger A, Afshar-Oromieh A. Combination of Forced Diuresis with Additional Late Imaging in 68Ga-PSMA-11 PET/CT: Effects on Lesion Visibility and Radiotracer Uptake. J Nucl Med 2021; 62:1252-1257. [PMID: 33547214 DOI: 10.2967/jnumed.120.257741] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/28/2020] [Indexed: 11/16/2022] Open
Abstract
Renal excretion of some prostate-specific membrane antigen (PSMA) ligands and consequently increased bladder activity can obscure locally relapsing prostate cancer lesions in PSMA PET/CT. Furthermore, additional late imaging in PSMA PET/CT provides a useful method to clarify uncertain findings. The aim of this retrospective study was to investigate a modified imaging protocol combining late additional imaging with hydration and forced diuresis in individuals undergoing additional late scanning for uncertain lesions or low prostate-specific antigen. Methods: We compared an older protocol with a newer one. In the old protocol, patients undergoing 68Ga-PSMA-11 PET/CT were examined at 90 min after injection, with 1 L of oral hydration beginning at 30 min after injection and 20 mg of furosemide given intravenously at 1 h after injection, followed by additional late imaging at 2.5 h after injection without further preparation. In the new protocol, a second group received the same procedure as before, with an additional 0.5 L of oral hydration and 10 mg of furosemide intravenously 30 min before the late imaging. We examined 132 patients (76 with the old protocol and 56 with the new one) with respect to urinary bladder activity (SUVmean), prostate cancer lesion uptake (SUVmax), and lesion contrast (ratio of tumor SUVmax to bladder SUVmean for local relapses and ratio of tumor SUVmax to gluteal-muscle SUVmean for nonlocal prostate cancer lesions). Results: Bladder activity was significantly greater for the old protocol in the late scans than for the new protocol (ratio of bladder activity at 2.5 h to bladder activity at 1.5 h, 2.33 ± 1.17 vs. 1.37 ± 0.50, P < 0.0001). Increased tumor SUVmax and contrast were seen at 2.5 h compared with 1.5 h (P < 0.0001 for old protocol; P = 0.02 for new protocol). Increased bladder activity for the old protocol resulted in decreased lesion-to-bladder contrast, which was not the case for the new protocol. Tumor-to-background ratios increased at late imaging for both protocols, but the increase was significantly lower for the new protocol. For the old protocol, comparing the 1.5-h to the 2.5-h acquisitions, 4 lesions in 4 patients (4/76 = 5.2% of the cohort) were visible at the postdiuresis 1.5-h acquisition but not at 2.5 h, having been obscured as a result of the higher bladder activity. In the new protocol, 2 of 56 (3.6%) patients had lesions visible only at late imaging, and 2 patients had lesions that could be better discriminated at late imaging. Conclusion: Although the combination of diuretics and hydration can be a useful method to increase the visualization and detectability of locally recurrent prostate cancer in standard 68Ga-PSMA-11 PET/CT, their effects do not sufficiently continue into additional late imaging. Additional diuresis and hydration are recommended to improve the visibility, detection, and diagnostic certainty of local recurrences.
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Affiliation(s)
- Ian Alberts
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | - Jan Niklas-Hünermund
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | - Christos Sachpekidis
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | | | - Clemens Mingels
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | - Lotte Dijkstra
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | - Karl Peter Bohn
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | - Tilman Läppchen
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | - Eleni Gourni
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | - Axel Rominger
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | - Ali Afshar-Oromieh
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
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Alberts IL, Seifert R, Rahbar K, Afshar-Oromieh A. Prostate Cancer Theranostics: From Target Description to Imaging. PET Clin 2021; 16:383-390. [PMID: 34053582 DOI: 10.1016/j.cpet.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Prostate-specific membrane antigen-PET/computed tomography (PSMA-PET/CT) is the investigation of choice for imaging prostate cancer. Demonstrating high diagnostic accuracy, PSMA-PET/CT detects disease at very early stages of recurrence, where the chances of a definitive cure may be at their greatest. A number of PSMA-radioligands are in established clinical routine, and there are currently only limited data and no single tracer can clearly be advocated over the others at present. Further clinical trial data, comparing and contrasting radiotracers and reporting outcome-based data are necessary to further increase the implementation of this very promising imaging modality.
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Affiliation(s)
- Ian L Alberts
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Robert Seifert
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany; Department of Nuclear Medicine, University Hospital Essen, Essen, Germany; West German Cancer Centre, Universitätsklinikum Essen, Hufelandstr. 55, 45147 Essen, Germany; German Cancer Consortium (DKTK), German Cancer Research Center, Im Neuenheimer Feld 280, D-69120 Heidelberg, Germany
| | - Kambiz Rahbar
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany; West German Cancer Centre, Universitätsklinikum Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Ali Afshar-Oromieh
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Comparison of Early Imaging and Imaging 60 min Post-Injection after Forced Diuresis with Furosemide in the Assessment of Local Recurrence in Prostate Cancer Patients with Biochemical Recurrence Referred for 68Ga-PSMA-11 PET/CT. Diagnostics (Basel) 2021; 11:diagnostics11071191. [PMID: 34208989 PMCID: PMC8304119 DOI: 10.3390/diagnostics11071191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/25/2021] [Accepted: 06/27/2021] [Indexed: 12/11/2022] Open
Abstract
Background: 68Ga-PSMA-11 PET/CT is a promising method for the assessment of local recurrence (LR) in prostate cancer (PCa) patients. The aim of this study was to evaluate the diagnostic performance of early 68Ga-PSMA-11 PET imaging in comparison to 68Ga-PSMA-11 PET imaging 60 min post-injection (p.i.) in the detection of LR in patients with biochemical recurrence (BR) of prostate carcinoma. Materials and Methods: 190 image sets of patients with BR in PCa who underwent 68Ga-PSMA-11 PET/CT were assessed retrospectively (median prostate specific antigen (PSA) value, 0.70 ng/mL (range, 0.1–105.6 ng/mL)). Patients received an early static scan of the pelvic area (median, 248 s p.i. (range, 56–923 s)) and a whole-body scan 60 min p.i. (median, 64 min p.i. (range, 45–100 min)) with intravenous administration of 20 mg furosemide i.v. at the time of tracer application, followed by intravenous hydration with 500 mL of sodium chloride (NaCl 0.9%). Assessment was based on visual analysis and calculation of the maximum standardized uptake value (SUVmax) of the pathologic lesions present in the prostate fossa found in the early PET imaging and 60 min PET scans. The scans were characterized as negative, positive, or equivocal. The results were compared, and the combination of early and 60 min p.i. imaging was evaluated. Results: Image assessment resulted in 30 (15.8%) positive, 17 (8.9%) equivocal, and 143 (75.3%) negative findings in early scans, and 28 (14.7%) positive, 25 (13.2%) equivocal, and 137 (72.1%) negative findings of LR in 60 min p.i. images. For combined image analysis, 33 (17.4%) cases were positive and 20 (10.5%) were equivocal. There was no statistical significance between the number of positive (p = 0.815), negative (p = 0.327), and equivocal (p = 0.152) findings. Furthermore, the combination of both scans showed no statistically significant differences for the positive and negative findings (p = 0.063). The median SUVmax was 4.9 (range, 2.0–55.2) for positive lesions in the early scans and 8.0 (range, 2.1–139.9) in the scans 60 min p.i. The median SUVmax for bladder activity was 2.5 (range, 0.9–12.2) in the early scans and 8.2 (range, 1.8–27.6) in the scans 60 min p.i. Conclusion: Early static imaging additional to 68Ga-PSMA-11 PET images acquired 60 min p.i. has limited value in patients prepared with furosemide and hydration, and showed no statistically significant change in the detection rate (DR) of LR and the number of equivocal findings. Based on our results, in departments following a protocol with forced diuresis, including furosemide, additional early static imaging cannot be routinely recommended for the assessment of BR in PCa patients.
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20
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Feasibility of late acquisition [68Ga]Ga-PSMA-11 PET/CT using a long axial field-of-view PET/CT scanner for the diagnosis of recurrent prostate cancer-first clinical experiences. Eur J Nucl Med Mol Imaging 2021; 48:4456-4462. [PMID: 34155538 PMCID: PMC8566391 DOI: 10.1007/s00259-021-05438-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/31/2021] [Indexed: 11/30/2022]
Abstract
Purpose While acquisition of images in [68 Ga]Ga-PSMA-11 following longer uptake times can improve lesion uptake and contrast, resultant imaging quality and count statistics are limited by the isotope’s half-life (68 min). Here, we present a series of cases demonstrating that when performed using a long axial field-of-view (LAFOV) PET/CT system, late imaging is feasible and can even provide improved image quality compared to regular acquisitions. Methods In this retrospective case series, we report our initial experiences with 10 patients who underwent standard imaging at 1 h p.i. following administration of 192 ± 36 MBq [68 Ga]Ga-PSMA-11 with additional late imaging performed at 4 h p.i. Images were acquired in a single bed position for 6 min at 1 h p.i. and 16 min p.i. at 4 h p.i. using a LAFOV scanner (106 cm axial FOV). Two experienced nuclear medicine physicians reviewed all scans in consensus and evaluated overall image quality (5-point Likert scale), lesion uptake in terms of standardised uptake values (SUV), tumour to background ratio (TBR) and target-lesion signal to background noise (SNR). Results Subjective image quality as rated on a 5-point Likert scale was only modestly lower for late acquisitions (4.2/5 at 4 h p.i.; 5/5 1 h p.i.), TBR was significantly improved (4 h: 3.41 vs 1 h: 1.93, p < 0.001) and SNR was improved with borderline significance (4 h: 33.02 vs 1 h: 24.80, p = 0.062) at later imaging. Images were obtained with total acquisition times comparable to routine examinations on standard axial FOV scanners. Conclusion Late acquisition in tandem with a LAFOV PET/CT resulted in improvements in TBR and SNR and was associated with only modest impairment in subjective visual imaging quality. These data show that later acquisition times for [68 Ga]Ga-PSMA-11 may be preferable when performed on LAFOV systems. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-021-05438-5.
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Mingels C, Sachpekidis C, Bohn KP, Hünermund JN, Schepers R, Fech V, Prenosil G, Rominger A, Afshar-Oromieh A, Alberts I. The influence of colour scale in lesion detection and patient-based sensitivity in [68Ga]Ga-PSMA-PET/CT. Nucl Med Commun 2021; 42:495-502. [PMID: 33481506 DOI: 10.1097/mnm.0000000000001364] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the influence of colour scales on the interpretation of [68Ga]Ga-PSMA-11 PET/CT for the diagnosis of recurrent prostate cancer. METHODS 50 consecutive patients who underwent [68Ga]Ga-PSMA-11 PET/CT for recurrent prostate cancer were selected for this retrospective study. The scans were randomised, anonymised and read by five different readers first in the visually nonlinear colour scale 'PET-rainbow'. Scans were then rerandomised and read in the visually linear colour scale 'hot-metal new'. For each scan in each colour scale the numbers of pathological, equivocal and benign lesions were noted. Scans where the majority of readers (≥3) reported at least one PET-positive lesion were recorded as 'pathological'. Patient-level sensitivity was obtained by composite standard with 14.8 ± 1.2 months of follow-up. RESULTS Increased numbers of lesions per patient were reported for all readers in PET-rainbow compared to hot-metal new (37.4 ± 15.2 vs. 33.9 ± 16.4, respectively, P = 0.0005). On a per-patient basis, 43 scans were rated pathological in PET-rainbow, compared to 39 in hot-metal new. Follow-up was available for 30 patients confirming 26 pathological scans with positive follow-up in PET-rainbow, and 23 in hot-metal new. Three pathological scans were missed in hot-metal new. Patient-level sensitivity was higher for PET-rainbow (0.96) compared to hot-metal new (0.85). Inter-reader reliability was higher for hot-metal new (Fleiss κ = 0.76) compared to PET-rainbow (Fleiss κ = 0.60). CONCLUSION Use of PET-rainbow was associated with improved lesion detection and sensitivity compared to hot-metal new, although at cost of reduced inter-rater agreement. Consequently, the use of PET-rainbow for clinical routine and future studies involving [68Ga]Ga-PSMA-11 is recommended.
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Affiliation(s)
- Clemens Mingels
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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22
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Alberts I, Hünermund JN, Sachpekidis C, Mingels C, Fech V, Bohn KP, Rominger A, Afshar-Oromieh A. The influence of digital PET/CT on diagnostic certainty and interrater reliability in [ 68Ga]Ga-PSMA-11 PET/CT for recurrent prostate cancer. Eur Radiol 2021; 31:8030-8039. [PMID: 33856522 PMCID: PMC8452558 DOI: 10.1007/s00330-021-07870-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/03/2021] [Accepted: 03/11/2021] [Indexed: 12/13/2022]
Abstract
Objective To investigate the impact of digital PET/CT on diagnostic certainty, patient-based sensitivity and interrater reliability. Methods Four physicians retrospectively evaluated two matched cohorts of patients undergoing [68Ga]Ga-PSMA-11 PET/CT on a digital (dPET/CT n = 65) or an analogue scanner (aPET/CT n = 65) for recurrent prostate cancer between 11/2018 and 03/2019. The number of equivocal and pathological lesions as well as the frequency of discrepant findings and the interrater reliability for the two scanners were compared. Results dPET/CT detected more lesions than aPET/CT (p < 0.001). A higher number of pathological scans were observed for dPET/CT (83% vs. 57%, p < 0.001). The true-positive rate at follow-up was 100% for dPET/CT compared to 84% for aPET/CT (p < 0.001). The proportion of lesions rated as non-pathological as a total of all PSMA-avid lesions detected for dPET/CT was comparable to aPET/CT (61.8% vs. 57.0%, p = 0.99). Neither a higher rate of diagnostically uncertain lesions (11.5% dPET/CT vs. 13.7% aPET/CT, p = 0.95) nor discrepant scans (where one or more readers differed in opinion as to whether the scan is pathological) were observed (18% dPET/CT vs. 17% aPET/CT, p = 0.76). Interrater reliability for pathological lesions was excellent for both scanner types (Cronbach’s α = 0.923 dPET/CT; α = 0.948 aPET/CT) and interrater agreement was substantial for dPET/CT (Krippendorf’s α = 0.701) and almost perfect in aPET/CT (α = 0.802). Conclusions A higher detection rate for pathological lesions for dPET/CT compared with aPET/CT in multiple readers was observed. This improved sensitivity was coupled with an improved true-positive rate and was not associated with increased diagnostic uncertainty, rate of non-specific lesions, or reduced interrater reliability. Key Points • New generation digital scanners detect more cancer lesions in men with prostate cancer. • When using digital scanners, the doctors are able to diagnose prostate cancer lesions with better certainty • When using digital scanners, the doctors do not disagree with each other more than with other scanner types.
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Affiliation(s)
- Ian Alberts
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, 3010, Bern, Switzerland.
| | - Jan-Niklas Hünermund
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, 3010, Bern, Switzerland
| | - Christos Sachpekidis
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, 3010, Bern, Switzerland
| | - Clemens Mingels
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, 3010, Bern, Switzerland
| | - Viktor Fech
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, 3010, Bern, Switzerland
| | - Karl Peter Bohn
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, 3010, Bern, Switzerland
| | - Axel Rominger
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, 3010, Bern, Switzerland
| | - Ali Afshar-Oromieh
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, 3010, Bern, Switzerland
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Shaygan B, Zukotynski K, Bénard F, Ménard C, Kuk J, Sistani G, Bauman G, Veit-Haibach P, Metser U. Canadian Urological Association best practice report: Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) and PET/magnetic resonance (MR) in prostate cancer. Can Urol Assoc J 2021; 15:162-172. [PMID: 33661093 DOI: 10.5489/cuaj.7268] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Prostate-specific membrane antigen (PSMA)-targeted positron emission tomography (PET) is increasingly being used worldwide as part of the clinical workup for men with prostate cancer. With high overall accuracy for the detection of prostate cancer, PSMA-targeted PET has an increasingly established role in the setting of biochemical failure after primary therapy and an evolving role in the setting of initial disease staging; its utility for guiding management in the setting of metastatic disease is less clear. Although the specificity is high, familiarization with potential pitfalls in the interpretation of PSMA-targeted PET, including knowledge of the causes for false-positive and negative examinations, is critical. The aim of this best practice report is to provide an illustrative discussion of the current and evolving clinical indications for PSMA-targeted PET, as well as a review of physiological radiopharmaceutical biodistribution and potential imaging pitfalls.
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Affiliation(s)
- Bobby Shaygan
- Department of Urology, McMaster University, Hamilton, ON, Canada
| | - Katherine Zukotynski
- Departments of Medicine and Radiology, McMaster University, Hamilton, ON, Canada
| | - François Bénard
- PET Functional Imaging, BC Cancer, Vancouver, BC, Canada.,Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Cynthia Ménard
- Department of Radiation Oncology, Université de Montréal, Montreal, QC, Canada
| | - Joda Kuk
- Grand River Regional Cancer Centre, Grand River Hospital, Kitchener, ON, Canada
| | - Golmehr Sistani
- Department of Medical Imaging, Western University, London, ON, Canada
| | - Glenn Bauman
- Department of Oncology, Western University, London, ON, Canada
| | | | - Ur Metser
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
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Alberts IL, Seide SE, Mingels C, Bohn KP, Shi K, Zacho HD, Rominger A, Afshar-Oromieh A. Comparing the diagnostic performance of radiotracers in recurrent prostate cancer: a systematic review and network meta-analysis. Eur J Nucl Med Mol Imaging 2021; 48:2978-2989. [PMID: 33550425 PMCID: PMC8263438 DOI: 10.1007/s00259-021-05210-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/18/2021] [Indexed: 01/07/2023]
Abstract
Purpose Many radiotracers are currently available for the detection of recurrent prostate cancer (rPC), yet many have not been compared head-to-head in comparative imaging studies. There is therefore an unmet need for evidence synthesis to guide evidence-based decisions in the selection of radiotracers. The objective of this study was therefore to assess the detection rate of various radiotracers for the rPC. Methods The PUBMED, EMBASE, and the EU and NIH trials databases were searched without date or language restriction for comparative imaging tracers for 13 radiotracers of principal interest. Key search terms included 18F-PSMA-1007, 18F-DCPFyl, 68Ga-PSMA-11, 18F-PSMA-11, 68Ga-PSMA-I&T, 68Ga-THP-PSMA, 64Cu-PSMA-617, 18F-JK-PSMA-7, 18F-Fluciclovine, 18F-FABC, 18F-Choline, 11C-Choline, and 68Ga-RM2. Studies reporting comparative imaging data in humans in rPC were selected. Single armed studies and matched pair analyses were excluded. Twelve studies with eight radiotracers were eligible for inclusion. Two independent reviewers screened all studies (using the PRISMA-NMA statement) for inclusion criteria, extracted data, and assessed risk of bias (using the QUADAS-2 tool). A network meta-analysis was performed using Markov-Chain Monte Carlo Bayesian analysis to obtain estimated detection rate odds ratios for each tracer combination. Results A majority of studies were judged to be at risk of publication bias. With the exception of 18F-PSMA-1007, little difference in terms of detection rate was revealed between the three most commonly used PSMA-radiotracers (68Ga-PSMA-11, 18F-PSMA-1007, 18F-DCFPyl), which in turn showed clear superiority to choline and fluciclovine using the derived network. Conclusion Differences in patient-level detection rates were observed between PSMA- and choline-radiotracers. However, there is currently insufficient evidence to favour one of the four routinely used PSMA-radioligands (PSMA-11, PSMA-1007, PSMA-I&T, and DCFPyl) over another owing to the limited evidence base and risk of publication bias revealed by our systematic review. A further limitation was lack of reporting on diagnostic accuracy, which might favour radiotracers with low specificity in an analysis restricted only to detection rate. The NMA derived can be used to inform the design of future clinical trials and highlight areas where current evidence is weak. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-021-05210-9.
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Affiliation(s)
- Ian Leigh Alberts
- Department of Nuclear Medicine. Inselspital, Bern University Hospital, University of Bern, Street: Freiburgstr. 18, CH-3010, Bern, Switzerland.
| | - Svenja Elizabeth Seide
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Clemens Mingels
- Department of Nuclear Medicine. Inselspital, Bern University Hospital, University of Bern, Street: Freiburgstr. 18, CH-3010, Bern, Switzerland
| | - Karl Peter Bohn
- Department of Nuclear Medicine. Inselspital, Bern University Hospital, University of Bern, Street: Freiburgstr. 18, CH-3010, Bern, Switzerland
| | - Kuangyu Shi
- Department of Nuclear Medicine. Inselspital, Bern University Hospital, University of Bern, Street: Freiburgstr. 18, CH-3010, Bern, Switzerland
| | - Helle D Zacho
- Department of Nuclear Medicine and Clinical Cancer Research Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
| | - Axel Rominger
- Department of Nuclear Medicine. Inselspital, Bern University Hospital, University of Bern, Street: Freiburgstr. 18, CH-3010, Bern, Switzerland
| | - Ali Afshar-Oromieh
- Department of Nuclear Medicine. Inselspital, Bern University Hospital, University of Bern, Street: Freiburgstr. 18, CH-3010, Bern, Switzerland
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25
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Afshar-Oromieh A, da Cunha ML, Wagner J, Haberkorn U, Debus N, Weber W, Eiber M, Holland-Letz T, Rauscher I. Performance of [ 68Ga]Ga-PSMA-11 PET/CT in patients with recurrent prostate cancer after prostatectomy-a multi-centre evaluation of 2533 patients. Eur J Nucl Med Mol Imaging 2021; 48:2925-2934. [PMID: 33543325 PMCID: PMC8263399 DOI: 10.1007/s00259-021-05189-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/02/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the performance of [68Ga]Ga-PSMA-11 PET/CT in the diagnosis of recurrent prostate cancer (PC) after prostatectomy in a large multicentre cohort. METHODS The centres, which contributed to this study, were the departments of nuclear medicine of Heidelberg (Germany), Technical University of Munich (Germany) and Albert Einstein Hospital of São Paulo (Brazil). A total of 2533 patients who were scanned with [68Ga]Ga-PSMA-11 PET/CT at 1 h p.i. due to recurrent PC after prostatectomy were included in this retrospective analysis. Exclusion criteria were as follows: patients with untreated primary tumour, previous chemotherapy or Xofigo®; those previously treated with exclusively external beam radiation therapy or HIFU; those referred for PSMA-therapy; and those treated with ADT (including first- and second-generation ADT) within the last 6 months. Potential influences of different factors such as PSA level, PSA doubling-time (PSADT), PSA velocity (PSAVel), Gleason Score (GSC, including the separate analysis of 7a and 7b), age and amount of injected tracer were evaluated in a multivariable analysis. RESULTS The rate of pathologic PET/CT-scans was 43% for PSA ≤ 0.2 ng/ml, 58% for PSA > 0.2 to ≤ 0.5, 72% for PSA > 0.5 to ≤ 1.0 and increased to a maximum of 93% for PSA > 10 ng/ml. A pathological PET/CT was significantly (p = 0.001) associated with PSA level and higher GSC. Amount of injected tracer, age, PSADT and PSAVel were not associated with a higher probability of a pathological scan. CONCLUSION [68Ga]Ga-PSMA-11 PET/CT at 1 h p.i. confirmed its high performance in the largest patient cohort yet analysed. Tumour detection showed a clear association with higher PSA and higher GSC. No association was found between a pathological [68Ga]Ga-PSMA-11 PET/CT and age, amount of injected tracer, PSADT or PSAVel.
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Affiliation(s)
- Ali Afshar-Oromieh
- Department of Nuclear Medicine, Heidelberg University Hospital, Heidelberg, Germany. .,Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, CH-3010, Bern, Switzerland.
| | | | - Jairo Wagner
- Department of Nuclear Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Uwe Haberkorn
- Department of Nuclear Medicine, Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Centre, Heidelberg, Germany
| | - Nils Debus
- Department of Nuclear Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Wolfgang Weber
- Department of Nuclear Medicine, Technical University of Munich, Munich, Germany
| | - Matthias Eiber
- Department of Nuclear Medicine, Technical University of Munich, Munich, Germany
| | - Tim Holland-Letz
- Department of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Isabel Rauscher
- Department of Nuclear Medicine, Technical University of Munich, Munich, Germany
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Chevalme YM, Boudali L, Gauthé M, Rousseau C, Skanjeti A, Merlin C, Robin P, Giraudet AL, Janier M, Talbot JN. Survey by the French Medicine Agency (ANSM) of the imaging protocol, detection rate, and safety of 68Ga-PSMA-11 PET/CT in the biochemical recurrence of prostate cancer in case of negative or equivocal 18F-fluorocholine PET/CT: 1084 examinations. Eur J Nucl Med Mol Imaging 2021; 48:2935-2950. [PMID: 33416958 PMCID: PMC8263442 DOI: 10.1007/s00259-020-05086-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/20/2020] [Indexed: 01/03/2023]
Abstract
Introduction Despite growing evidence of a superior diagnostic performance of 68Ga-PSMA-11 over 18F-fluorocholine (FCH) PET/CT, the number of PET/CT centres able to label on site with gallium-68 is still currently limited. Therefore, patients with biochemical recurrence (BCR) of prostate cancer frequently undergo FCH as the 1st-line PET/CT. Actually, the positivity rate (PR) of a second-line PSMA-11 PET/CT in case of negative FCH PET/CT has only been reported in few short series, in a total of 185 patients. Our aims were to check (1) whether the excellent PR reported with PSMA-11 is also obtained in BCR patients whose recent FCH PET/CT was negative or equivocal; (2) in which biochemical and clinical context a high PSMA-11 PET/CT PR may be expected in those patients, in particular revealing an oligometastatic pattern; (3) whether among the various imaging protocols for PSMA-11 PET/CT used in France, one yields a significantly highest PR; (4) the tolerance of PSMA-11. Patients and methods Six centres performed 68Ga-PSMA-11 PET/CTs during the first 3 years of its use in France. Prior to each PET/CT, the patient’s data were submitted prospectively for authorisation to ANSM, the French Medicine Agency. The on-site readings of 1084 PSMA-11 PET/CTs in BCR patients whose recent FCH PET/CTs resulted negative or equivocal were pooled and analysed. Results (1) The overall PR was 68%; for a median serum PSA level (sPSA) of 1.7 ng/mL, an oligometastatic pattern (1–3 foci) was observed in 31% of the cases overall; (2) PR was significantly related to sPSA (from 41% if < 0.2 ng/mL to 81% if ≥ 2 ng/mL), to patients’ age, to initial therapy (64% if prostatectomy vs. 85% without prostatectomy due to frequent foci in the prostate fossa), to whether FCH PET/CT was negative or equivocal (PR = 62% vs. 82%), and to previous BCR (PR = 63% for 1st BCR vs. 72% in case of previous BCR); (3) no significant difference in PR was found according to the imaging protocol: injected activity, administration of a contrast agent and/or of furosemide, dose length product, one single or multiple time points of image acquisition; (4) no adverse event was reported after PSMA-11 injection, even associated with a contrast agent and/or furosemide. Conclusion Compared with the performance of PSMA-11 PET/CT in BCR reported independently of FCH PET/CT in 6 large published series (n > 200), the selection based on FCH PET/CT resulted in no difference of PSMA-11 PR for sPSA < 1 ng/mL but in a slightly lower PR for sPSA ≥ 1 ng/mL, probably because FCH performs rather well at this sPSA and very occult BCR was over-represented in our cohort. An oligometastatic pattern paving the way to targeted therapy was observed in one fourth to one third of the cases, according to the clinico-biochemical context of the BCR. Systematic dual or triple acquisition time points or administration of a contrast agent and/or furosemide did not bring a significant added value for PSMA-11 PET/CT positivity and should be decided on individual bases.
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Affiliation(s)
- Yanna-Marina Chevalme
- Direction des médicaments en oncologie, hématologie, transplantation, néphrologie, thérapie cellulaire, produits sanguins, et radiopharmaceutiques, Agence Nationale de Sécurité du Médicament et des produits de santé (ANSM), 143 Bd Anatole, F93200, St Denis, France.
| | - Lotfi Boudali
- Direction des médicaments en oncologie, hématologie, transplantation, néphrologie, thérapie cellulaire, produits sanguins, et radiopharmaceutiques, Agence Nationale de Sécurité du Médicament et des produits de santé (ANSM), 143 Bd Anatole, F93200, St Denis, France
| | - Mathieu Gauthé
- Service de médecine nucléaire, Hôpital Tenon, AP-HP Sorbonne Université, Paris, France
| | - Caroline Rousseau
- Nuclear Medicine Unit, ICO René Gauducheau, CNRS, Inserm, CRCINA, Nantes University, F-44000, Nantes, France
| | - Andrea Skanjeti
- Nuclear Medicine Department, Hospices Civils de Lyon, EA 3738, Université Claude Bernard Lyon 1, Lyon, France
| | - Charles Merlin
- Nuclear Medicine Department, Cancer Center Jean PERRIN, Clermont-Ferrand, France
| | - Philippe Robin
- Service de Médecine Nucléaire, EA 3878 (GETBO), Centre Hospitalier Régional et Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | | | - Marc Janier
- Nuclear Medicine Department, Hospices Civils de Lyon, EA 3738, Université Claude Bernard Lyon 1, Lyon, France.,Comité permanent de l'ANSM, Médicaments de diagnostic et de médecine nucléaire, St Denis, France
| | - Jean-Noël Talbot
- Service de médecine nucléaire, Hôpital Tenon, AP-HP Sorbonne Université, Paris, France.,Comité permanent de l'ANSM, Médicaments de diagnostic et de médecine nucléaire, St Denis, France
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Hoffmann MA, Buchholz HG, Wieler HJ, Rosar F, Miederer M, Fischer N, Schreckenberger M. Dual-Time Point [ 68Ga]Ga-PSMA-11 PET/CT Hybrid Imaging for Staging and Restaging of Prostate Cancer. Cancers (Basel) 2020; 12:cancers12102788. [PMID: 32998432 PMCID: PMC7600341 DOI: 10.3390/cancers12102788] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 12/13/2022] Open
Abstract
Simple Summary Early diagnosis and tumor characterization of prostate cancer (PCa) are important for accurate treatment. [68Ga]Ga-PSMA-11 PET/CT turns out to constitute a major step toward improved diagnostic procedures to detect primary, recurrent, and metastatic PCa. The aim of our study is to evaluate the effect of a second imaging modality for the staging and restaging of PCa by possibly detecting additional PCa lesions due to the well-known increase of PSMA uptake over time. There was a significant increase in tracer uptake on delayed images in comparison to early [68Ga]Ga-PSMA-11 PET/CT in our study, but the lesion positivity rate was comparable. However, in a few individual cases, additional delayed scans provided an information advantage in PCa lesion detection. The findings of our study are likely to be of major interest to clinicians as well as to researchers defining the algorithms that are necessary to implement this promising method with its specific tracer into clinical routine. Abstract Routine [68Ga]Ga-PSMA-11 PET/CT (one hour post-injection) has been shown to accurately detect prostate cancer (PCa) lesions. The goal of this study is to evaluate the benefit of a dual-time point imaging modality for the staging and restaging of PCa patients. Biphasic [68Ga]Ga-PSMA-11 PET/CT of 233 patients, who underwent early and late scans (one/three hours post-injection), were retrospectively studied. Tumor uptake and biphasic lesion detection for 215 biochemically recurrent patients previously treated for localized PCa (prostatectomized patients (P-P)/irradiated patients (P-I) and 18 patients suspected of having primary PCa (P-T) were separately evaluated. Late [68Ga]Ga-PSMA-11 PET/CT imaging detected 554 PCa lesions in 114 P-P patients, 187 PCa lesions in 33 P-I patients, and 47 PCa lesions in 13 P-T patients. Most patients (106+32 P-P/P-I, 13 P-T) showed no additional PCa lesions. However, 11 PSMA-avid lesions were only detected in delayed images, and 33 lesions were confirmed as malignant by a SUVmax increase. The mean SUVmax of pelvic lymph node metastases was 25% higher (p < 0.001) comparing early and late PET/CT. High positivity rates from routine [68Ga]Ga-PSMA-11 PET/CT for the staging and restaging of PCa patients were demonstrated. There was no decisive influence of additional late imaging with PCa lesion detection on therapeutic decisions. However, in a few individual cases, additional delayed scans provided an information advantage in PCa lesion detection due to higher tracer uptake and improved contrast.
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Affiliation(s)
- Manuela A. Hoffmann
- Department of Occupational Health & Safety, Federal Ministry of Defense, 53123 Bonn, Germany
- Clinic of Nuclear Medicine, Johannes Gutenberg-University, 55101 Mainz, Germany; (H.-G.B.); (F.R.); (M.M.); (M.S.)
- Correspondence:
| | - Hans-Georg Buchholz
- Clinic of Nuclear Medicine, Johannes Gutenberg-University, 55101 Mainz, Germany; (H.-G.B.); (F.R.); (M.M.); (M.S.)
| | - Helmut J Wieler
- Clinic of Nuclear Medicine, Bundeswehr Central Hospital, 56072 Koblenz, Germany;
| | - Florian Rosar
- Clinic of Nuclear Medicine, Johannes Gutenberg-University, 55101 Mainz, Germany; (H.-G.B.); (F.R.); (M.M.); (M.S.)
- Department of Nuclear Medicine, Saarland University Medical Center, 66421 Homburg, Germany
| | - Matthias Miederer
- Clinic of Nuclear Medicine, Johannes Gutenberg-University, 55101 Mainz, Germany; (H.-G.B.); (F.R.); (M.M.); (M.S.)
| | - Nicolas Fischer
- Department of Urology, University of Cologne, 50937 Cologne, Germany;
| | - Mathias Schreckenberger
- Clinic of Nuclear Medicine, Johannes Gutenberg-University, 55101 Mainz, Germany; (H.-G.B.); (F.R.); (M.M.); (M.S.)
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Abstract
Prostate cancer is the commonest malignancy to affect men in the United Kingdom. Extraprostatic disease detection at staging and in the setting of biochemical recurrence is essential in determining treatment strategy. Conventional imaging including computed tomography and bone scintigraphy are limited in their ability to detect sites of loco-regional nodal and metastatic bone disease, particularly at clinically relevant low prostate-specific antigen levels. The use of positron emission tomography-computed tomography has helped overcome these deficiencies and is leading a paradigm shift in the management of prostate cancer using a wide range of radiopharmaceuticals. Their mechanisms of action, utility in both staging and biochemical recurrence, and comparative strengths and weaknesses will be covered in this article.
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Affiliation(s)
- Manil Subesinghe
- King's College London & Guy's & St. Thomas' PET Centre, St. Thomas' Hospital, London, UK; Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
| | - Meghana Kulkarni
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Gary J Cook
- King's College London & Guy's & St. Thomas' PET Centre, St. Thomas' Hospital, London, UK; Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
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Uprimny C, Bayerschmidt S, Kroiss AS, Fritz J, Nilica B, Svirydenka A, Decristoforo C, di Santo G, von Guggenberg E, Horninger W, Virgolini IJ. Impact of forced diuresis with furosemide and hydration on the halo artefact and intensity of tracer accumulation in the urinary bladder and kidneys on [ 68Ga]Ga-PSMA-11-PET/CT in the evaluation of prostate cancer patients. Eur J Nucl Med Mol Imaging 2020; 48:123-133. [PMID: 32385647 DOI: 10.1007/s00259-020-04846-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/28/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE to assess the influence of intravenous hydration and forced diuresis with furosemide in two different dosages (20 vs 40 mg) on the intensity of tracer accumulation in the urinary collection system and on the occurrence of halo artefact surrounding the urinary bladder and kidneys in [68Ga]Ga-PSMA-11-PET/CT scans. MATERIALS AND METHODS Comparison of four groups with 50 patients each, receiving different preparation prior to [68Ga]Ga-PSMA-11-PET/CT. Group one, no preparation. Group two, 500 ml sodium chloride administered immediately after tracer injection. Group three, 500 ml sodium chloride and injection of 20 mg furosemide immediately after tracer administration. Group four, 500 ml sodium chloride and injection of 40 mg furosemide immediately after tracer injection. Images were judged visually whether halo artefact was present; semiquantitative measurements were performed with standardised uptake value (SUV). RESULTS Halo artefact of the urinary bladder was present in twelve patients without preparation, in eight patients receiving only sodium chloride, in one patient injected with 20 mg furosemide/sodium chloride and in two patients receiving 40 mg furosemide/sodium chloride, showing a median SUVmean in the bladder of 45.8, 14.4, 4.6 and 5.8, respectively. Differences between patient group without preparation and the two groups with furosemide/sodium chloride were statistically significant. Patient groups receiving 20 mg furosemide and 40 mg furosemide did not differ significantly. Renal halo artefacts were observed in 15 patients of group one, in ten patients of group two, in 14 patients of group three and in 14 patients of group four, with corresponding median SUVmean values of 33.9, 32.0, 37.8 and 30.4 (no statistically significant differences). CONCLUSION Performing [68Ga]Ga-PSMA-11-PET/CT, intravenous injection of 20-mg furosemide and 500-ml sodium chloride significantly reduces the number of bladder halo artefacts and intensity of tracer accumulation in the urinary bladder. A total of 40 mg furosemide does not further improve results.
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Affiliation(s)
- Christian Uprimny
- Department of Nuclear Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Steffen Bayerschmidt
- Department of Nuclear Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alexander Stephan Kroiss
- Department of Nuclear Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Josef Fritz
- Department of Medical Statistics, Informatics and Health Economics, Medical University Innsbruck, Innsbruck, Austria
| | - Bernhard Nilica
- Department of Nuclear Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Anna Svirydenka
- Department of Nuclear Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Clemens Decristoforo
- Department of Nuclear Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gianpaolo di Santo
- Department of Nuclear Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Elisabeth von Guggenberg
- Department of Nuclear Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | | | - Irene Johanna Virgolini
- Department of Nuclear Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
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