1
|
Roberts MJ, Maurer T, Perera M, Eiber M, Hope TA, Ost P, Siva S, Hofman MS, Murphy DG, Emmett L, Fendler WP. Using PSMA imaging for prognostication in localized and advanced prostate cancer. Nat Rev Urol 2023; 20:23-47. [PMID: 36473945 DOI: 10.1038/s41585-022-00670-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 12/12/2022]
Abstract
The use of prostate-specific membrane antigen (PSMA)-directed applications in modern prostate cancer management has evolved rapidly over the past few years, helping to establish new treatment pathways and provide further insights into prostate cancer biology. However, the prognostic implications of PSMA-PET have not been studied systematically, owing to rapid clinical implementation without long follow-up periods to determine intermediate-term and long-term oncological outcomes. Currently available data suggest that traditional prognostic factors and survival outcomes are associated with high PSMA expression (both according to immunohistochemistry and PET uptake) in men with localized and biochemically recurrent disease. Treatment with curative intent (primary and/or salvage) often fails when PSMA-positive metastases are present; however, the sensitivity of PSMA-PET in detecting all metastases is poor. Low PSMA-PET uptake in recurrent disease is a favourable prognostic factor; however, it can be associated with poor prognosis in conjunction with high 18F-fluorodeoxyglucose uptake in metastatic castration-resistant prostate cancer. Clinical trials embedding PSMA-PET for guiding management with reliable oncological outcomes are needed to support ongoing clinical use.
Collapse
Affiliation(s)
- Matthew J Roberts
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
- University of Queensland Centre for Clinical Research, Faculty of Medicine, Brisbane, Queensland, Australia.
- Department of Urology, Redcliffe Hospital, Brisbane, Queensland, Australia.
| | - Tobias Maurer
- Martini-Klinik Prostate Cancer Center, Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marlon Perera
- Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Matthias Eiber
- Department of Nuclear Medicine, Technical University of Munich, Munich, Germany
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Piet Ost
- Department of Radiation Oncology, Iridium Network, GZA Ziekenhuizen, Antwerp, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Shankar Siva
- Peter MacCallum Cancer Centre, Radiation Oncology, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, Melbourne University, Parkville, Victoria, Australia
| | - Michael S Hofman
- Sir Peter MacCallum Department of Oncology, Melbourne University, Parkville, Victoria, Australia
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Prostate Cancer Theranostics and Imaging Centre of Excellence, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Declan G Murphy
- Sir Peter MacCallum Department of Oncology, Melbourne University, Parkville, Victoria, Australia
- Prostate Cancer Theranostics and Imaging Centre of Excellence, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Wolfgang P Fendler
- Department of Nuclear Medicine, University of Duisburg-Essen, Essen, Germany
- PET Committee of the German Society of Nuclear Medicine, Goettingen, Germany
| |
Collapse
|
2
|
Nabian N, Ghalehtaki R, Couñago F. Necessity of Pelvic Lymph Node Irradiation in Patients with Recurrent Prostate Cancer after Radical Prostatectomy in the PSMA PET/CT Era: A Narrative Review. Biomedicines 2022; 11:biomedicines11010038. [PMID: 36672547 PMCID: PMC9855373 DOI: 10.3390/biomedicines11010038] [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: 10/04/2022] [Revised: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 12/28/2022] Open
Abstract
The main prostate cancer (PCa) treatments include surgery or radiotherapy (with or without ADT). However, none of the suggested treatments eliminates the risk of lymph node metastases. Conventional imaging methods, including MRI and CT scanning, are not sensitive enough for the diagnosis of lymph node metastases; however, the novel imaging method, PSMA PET/CT scanning, has provided valuable information about the pelvic LN involvement in patients with recurrent PCa (RPCa) after radical prostatectomy. The high sensitivity and negative predictive value enable accurate N staging in PCa patients. In this narrative review, we summarize the evidence on the treatment and extent of radiation in prostate-only or whole-pelvis radiation in patients with positive and negative LN involvement on PSMA PET/CT scans.
Collapse
Affiliation(s)
- Naeim Nabian
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran P.O. Box 1419733141, Iran
- Department of Radiation Oncology, Cancer Institute, Tehran University of Medical Sciences, Tehran P.O. Box 1419733141, Iran
| | - Reza Ghalehtaki
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran P.O. Box 1419733141, Iran
- Department of Radiation Oncology, Cancer Institute, Tehran University of Medical Sciences, Tehran P.O. Box 1419733141, Iran
- Correspondence:
| | - Felipe Couñago
- Department of Radiation Oncology, San Francisco de Asís and La Milagrosa Hospitals, GenesisCare, 28010 Madrid, Spain
| |
Collapse
|
3
|
Terlizzi M, Limkin EJ, Moukasse Y, Blanchard P. Adjuvant or Salvage Radiation Therapy for Prostate Cancer after Prostatectomy: Current Status, Controversies and Perspectives. Cancers (Basel) 2022; 14:cancers14071688. [PMID: 35406460 PMCID: PMC8996903 DOI: 10.3390/cancers14071688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary The management of patients with biochemical recurrence after prostatectomy has undergone significant changes in recent years. Currently, close monitoring of prostate-specific antigen (PSA) with early salvage radiotherapy (RT) in case of recurrence is the standard of care based on several randomized trials and a meta-analysis that has demonstrated its non-inferiority to adjuvant RT. Uncertainties remain regarding the management of patients at very high risk of recurrence, including appropriate selection criteria for adjuvant hormone therapy, and the role of imaging in refining the treatment strategy. This review explains this paradigm shift, raises points of controversy, and suggests ways to think about the future. Abstract Nearly one-third of the patients who undergo prostatectomy for prostate cancer have a biochemical recurrence (BCR) during follow-up. While several randomized trials have shown that adjuvant radiation therapy (aRT) improves biochemical control, this strategy has not been widely used because of the risk of toxicity and the fear of overtreating patients who would not have relapsed. In addition, the possibility of close PSA monitoring in the era of ultrasensitive assays enables to anticipate early salvage strategies (sRT). Three recent randomized trials and their meta-analysis have confirmed that aRT does not improve event-free survival compared to sRT, imposing the latter as the new standard of treatment. The addition of androgen deprivation therapy (ADT) to RT has been shown to improve biochemical control and metastasis-free survival, but the precise definition of to whom it should be proposed is still a matter of debate. The development of genomic tests or the use of artificial intelligence will allow more individualized treatment in the future. Therapeutic intensification with the combination of new-generation hormone therapy and RT is under study. Finally, the growing importance of metabolic imaging (PET/CT) due to its performance especially for low PSA levels will help in further personalizing management strategies.
Collapse
|
4
|
Ceci F, Rovera G, Iorio GC, Guarneri A, Chiofalo V, Passera R, Oderda M, Dall'Armellina S, Liberini V, Grimaldi S, Bellò M, Gontero P, Ricardi U, Deandreis D. Event-free survival after 68 Ga-PSMA-11 PET/CT in recurrent hormone-sensitive prostate cancer (HSPC) patients eligible for salvage therapy. Eur J Nucl Med Mol Imaging 2022; 49:3257-3268. [PMID: 35217883 PMCID: PMC9250462 DOI: 10.1007/s00259-022-05741-9] [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: 11/22/2021] [Accepted: 02/17/2022] [Indexed: 11/30/2022]
Abstract
Background/aim Prostate-specific-membrane-antigen/positron emission tomography (PSMA-PET) detects with high accuracy disease-recurrence, leading to changes in the management of biochemically-recurrent (BCR) prostate cancer (PCa). However, data regarding the oncological outcomes of patients who performed PSMA-PET are needed. The aim of this study was to evaluate the incidence of clinically relevant events during follow-up in patients who performed PSMA-PET for BCR after radical treatment. Materials and methods This analysis included consecutive, hormone-sensitive, hormone-free, recurrent PCa patients (HSPC) enrolled through a prospective study. All patients were eligible for salvage therapy, having at least 24 months of follow-up after PSMA-PET. The primary endpoint was the Event-Free Survival (EFS), defined as the time between the PSMA-PET and the date of event/last follow-up. The Kaplan–Meier method was used to estimate the EFS curves. EFS was also investigated by Cox proportional hazards regression. Events were defined as death, radiological progression, or PSA recurrence after therapy. Results One-hundred and seventy-six (n = 176) patients were analyzed (median PSA 0.62 [IQR: 0.43–1.00] ng/mL; median follow-up of 35.4 [IQR: 26.5–40.3] months). The EFS was 78.8% at 1 year, 65.2% (2 years), and 52.2% (3 years). Patients experiencing events during study follow-up had a significantly higher median PSA (0.81 [IQR: 0.53–1.28] vs 0.51 [IQR: 0.36–0.80] ng/mL) and a lower PSA doubling time (PSAdt) (5.4 [IQR: 3.7–11.6] vs 12.7 [IQR: 6.6–24.3] months) (p < 0.001) compared to event-free patients. The Kaplan–Meier curves showed that PSA > 0.5 ng/mL, PSAdt ≤ 6 months, and a positive PSMA-PET result were associated with a higher event rate (p < 0.01). No significant differences of event rates were observed in patients who received changes in therapy management after PSMA-PET vs. patients who did not receive therapy changes. Finally, PSA > 0.5 ng/mL and PSAdt ≤ 6 months were statistically significant event-predictors in multivariate model (p < 0.001). Conclusion Low PSA and long PSAdt were significant predictors of longer EFS. A lower incidence of events was observed in patients having negative PSMA-PET, since longer EFS was significantly more probable in case of a negative scan. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-022-05741-9.
Collapse
Affiliation(s)
- Francesco Ceci
- Nuclear Medicine, Department of Medical Sciences, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy. .,Division of Nuclear Medicine, IEO European Institute of Oncology IRCCS, Milan, Italy. .,Department of Oncology and Hemato-Oncolology, University of Milan, Milan, Italy. .,Nuclear Medicine Department, S. Croce E Carle Hospital, Cuneo, Italy.
| | - Guido Rovera
- Nuclear Medicine, Department of Medical Sciences, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy.,Section of Nuclear Medicine, University Department of Radiological Sciences and Haematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Carlo Iorio
- Radiation Oncology, Department of Oncology, AOU Città Della Salute E Della Scienza Di Torino, Turin, Italy
| | - Alessia Guarneri
- Radiation Oncology, Department of Oncology, AOU Città Della Salute E Della Scienza Di Torino, Turin, Italy
| | - Valeria Chiofalo
- Radiation Oncology, Department of Oncology, AOU Città Della Salute E Della Scienza Di Torino, Turin, Italy
| | - Roberto Passera
- Nuclear Medicine, Department of Medical Sciences, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy
| | - Marco Oderda
- Urology, Department of Surgical Sciences, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy
| | - Sara Dall'Armellina
- Nuclear Medicine, Department of Medical Sciences, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy
| | - Virginia Liberini
- Nuclear Medicine, Department of Medical Sciences, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy
| | - Serena Grimaldi
- Nuclear Medicine, Department of Medical Sciences, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy
| | - Marilena Bellò
- Nuclear Medicine, Department of Medical Sciences, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy
| | - Paolo Gontero
- Urology, Department of Surgical Sciences, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy
| | - Umberto Ricardi
- Section of Nuclear Medicine, University Department of Radiological Sciences and Haematology, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Oncology, University of Turin, Turin, Italy
| | - Désirée Deandreis
- Nuclear Medicine, Department of Medical Sciences, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy
| |
Collapse
|
5
|
von Eyben FE, Soydal C, von Eyben R. 68Ga-PSMA PET/CT for Patients with PSA Relapse after Radical Prostatectomy or External Beam Radiotherapy. Diagnostics (Basel) 2021; 11:diagnostics11040622. [PMID: 33808350 PMCID: PMC8066852 DOI: 10.3390/diagnostics11040622] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/25/2021] [Accepted: 03/25/2021] [Indexed: 11/16/2022] Open
Abstract
The study aimed to summarize clinical characteristics associated with Gallium-68-prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (68Ga-PSMA PET/CT) scans as patients were restaged for prostate-specific antigen (PSA) relapse after radical prostatectomy (RP) or external beam radiotherapy (EBRT). Our analyses included multiple cox regression analyses. The study evaluated 95 patients with rising values of PSAs after RP and after EBRT. Sixty 63% of patients had a positive 68Ga-PSMA PET/CT scan. Twelve patients (13%) had a positive site in the prostate bed, 29 patients (30%) had a positive site in the regional lymph nodes, and 19 (20%) had positive sites in distant organs. After four years follow-up, 21 patients (22%) died. Using multiple Cox regression analyses, the number of positive sites on the 68Ga-PSMA PET/CT scan significantly predicted overall survival (OS) (p = 0.0001), whereas risk score and regional locations of the positive sites were not significant in the multiple Cox regression analyses. Our study indicates that the specific findings of 68Ga-PSMA PET/CT scans are important because detailed findings of the scans predict the outcome after salvage treatment of patients with PSA relapse examined with 68Ga-PSMA PET/CT scans.
Collapse
Affiliation(s)
| | - Cigdem Soydal
- Department of Nuclear Medicine, Ankara University, 06560 Ankara, Turkey;
| | - Rie von Eyben
- Department of Radiation Oncology, Stanford University, Stanford, CA 94350, USA;
| |
Collapse
|
6
|
Diagnostic value of 18F-FDG PET/CT in patients with biochemical recurrent prostate cancer and negative 68Ga-PSMA PET/CT. Eur J Nucl Med Mol Imaging 2021; 48:2970-2977. [PMID: 33528607 DOI: 10.1007/s00259-021-05221-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/25/2021] [Indexed: 01/23/2023]
Abstract
PURPOSE 68Ga-PSMA PET/CT has a high detection rate in prostate cancer patients with biochemical recurrence (BCR). However, few studies have reported other imaging methods for BCR with negative 68Ga-PSMA PET/CT findings. We investigated the value of 18F-FDG compared with 68Ga-PSMA and identified BCR patients with 68Ga-PSMA-negative findings who are most likely to benefit from 18F-FDG PET/CT. METHODS Seventy-two BCR patients with negative 68Ga-PSMA PET/CT findings were retrospectively identified from 510 patients who underwent concomitant 68Ga-PSMA and 18F-FDG PET/CT between June 2018 and August 2020. Patients were categorised into groups with positive or negative 18F-FDG PET/CT findings. Differences in patients' characteristics between these two groups and predictors of positive 18F-FDG findings were analysed. RESULTS The detection rate of 18F-FDG PET/CT was 16.7% (12/72) in BCR patients with 68Ga-PSMA-negative findings. PSA and Gleason score were significantly higher in the 18F-FDG-positive group than in the 18F-FDG-negative group (P < 0.001 and P < 0.001, respectively). A multivariate analysis indicated that PSA (PSA ≥2.3 ng/mL) and Gleason score (Gleason score ≥ 8) correlated with 18F-FDG-positive findings (P < 0.001 and P = 0.015, respectively). The probabilities of 18F-FDG-positive findings in the low-potential (PSA <2.3 ng/mL and Gleason score <8), moderate-potential (PSA <2.3 ng/mL and Gleason score ≥ 8 or PSA ≥2.3 ng/mL and Gleason score <8), and high-potential (PSA ≥2.3 ng/mL and Gleason score ≥ 8) groups were 0%, 11.5%, and 90.0%, respectively (P < 0.001). CONCLUSION PSA level and Gleason score are independent predictors of 18F-FDG-positive findings, and BCR patients with 68Ga-PSMA-negative findings with high PSA and Gleason score are most likely to benefit from 18F-FDG PET/CT.
Collapse
|