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Mari A, Cadenar A, Giudici S, Cianchi G, Albisinni S, Autorino R, Di Maida F, Gandaglia G, Mir MC, Valerio M, Marra G, Zattoni F, Bianchi L, Lombardo R, Shariat SF, Roupret M, Bauckneht M, Vaggelli L, De Nunzio C, Minervini A. A systematic review and meta-analysis to evaluate the diagnostic accuracy of PSMA PET/CT in the initial staging of prostate cancer. Prostate Cancer Prostatic Dis 2024:10.1038/s41391-024-00850-y. [PMID: 38822051 DOI: 10.1038/s41391-024-00850-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/04/2024] [Accepted: 05/20/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Positron Emission Tomography-Computed Tomography using Prostate-Specific Membrane Antigen (PSMA PET/CT) is notable for its superior sensitivity and specificity in detecting recurrent PCa and is under investigation for its potential in pre-treatment staging. Despite its established efficacy in nodal and metastasis staging in trial setting, its role in primary staging awaits fuller validation due to limited evidence on oncologic outcomes. This systematic review and meta-analysis aims to appraise the diagnostic accuracy of PSMA PET/CT compared to CI for comprehensive PCa staging. METHODS Medline, Scopus and Web of science databases were searched till March 2023. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. Primary outcomes were specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV) of PSMA PET/CT for local, nodal and metastatic staging in PCa patients. Due to the unavailability of data, a meta-analysis was feasible only for detection of seminal vesicles invasion (SVI) and LNI. RESULTS A total of 49 studies, comprising 3876 patients, were included. Of these, 6 investigated accuracy of PSMA PET/CT in detection of SVI. Pooled sensitivity, specificity, PPV and NPV were 42.29% (95%CI: 29.85-55.78%), 87.59% (95%CI: 77.10%-93.67%), 93.39% (95%CI: 74.95%-98.52%) and 86.60% (95%CI: 58.83%-96.69%), respectively. Heterogeneity analysis revealed significant variability for PPV and NPV. 18 studies investigated PSMA PET/CT accuracy in detection of LNI. Aggregate sensitivity, specificity, PPV and NPV were 43.63% (95%CI: 34.19-53.56%), 85.55% (95%CI: 75.95%-91.74%), 67.47% (95%CI: 52.42%-79.6%) and 83.61% (95%CI: 79.19%-87.24%). No significant heterogeneity was found between studies. CONCLUSIONS The present systematic review and meta-analysis highlights PSMA PET-CT effectiveness in detecting SVI and its good accuracy in LNI compared to CI. Nonetheless, it also reveals a lack of high-quality research on its performance in clinical T staging, extraprostatic extension and distant metastasis evaluation, emphasizing the need for further rigorous studies.
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Affiliation(s)
- Andrea Mari
- Oncologic Minimally Invasive Urology and Andrology Unit, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, 50121, Florence, Italy.
| | - Anna Cadenar
- Oncologic Minimally Invasive Urology and Andrology Unit, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, 50121, Florence, Italy
| | - Sofia Giudici
- Oncologic Minimally Invasive Urology and Andrology Unit, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, 50121, Florence, Italy
| | - Gemma Cianchi
- Oncologic Minimally Invasive Urology and Andrology Unit, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, 50121, Florence, Italy
| | - Simone Albisinni
- Urology Unit, Department of Surgical Sciences, Tor Vergata University Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Riccardo Autorino
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
| | - Fabrizio Di Maida
- Oncologic Minimally Invasive Urology and Andrology Unit, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, 50121, Florence, Italy
| | - Giorgio Gandaglia
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy
| | - M Carmen Mir
- Department of Urology, Hospital Universitario La Ribera, Valencia, Spain
| | - Massimo Valerio
- Department of Urology, University Hospital of Geneva, Geneva, Switzerland
| | - Giancarlo Marra
- Division of Urology, Department of Surgical Sciences, University of Turin and Città della Salute e della Scienza, Turin, Italy
| | - Fabio Zattoni
- Department Surgery, Oncology and Gastroenterology, Urologic Unit, University of Padova, Padova, Italy
| | - Lorenzo Bianchi
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Riccardo Lombardo
- Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria
- Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
- Department of Urology, Weill Cornell Medical College, New York, NY, 10065, USA
- Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- European Association of Urology Research Foundation, Arnhem, The Netherlands
- Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordanien
| | - Morgan Roupret
- Urology, Predictive Onco-Urology, AP-HP, Urology Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Matteo Bauckneht
- Nuclear Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Luca Vaggelli
- Nuclear Medicine Division, Careggi University Hospital, Florence, Italy
| | - Cosimo De Nunzio
- Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Andrea Minervini
- Oncologic Minimally Invasive Urology and Andrology Unit, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, 50121, Florence, Italy
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Sofia L, Bauckneht M. PSMA PET/CT in the low- to intermediate-risk prostate cancer: when and why? Asian J Androl 2024:00129336-990000000-00171. [PMID: 38534099 DOI: 10.4103/aja20244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 01/28/2024] [Indexed: 03/28/2024] Open
Affiliation(s)
- Luca Sofia
- Department of Health Sciences (DISSAL), University of Genova, Genova 16132, Italy
| | - Matteo Bauckneht
- Department of Health Sciences (DISSAL), University of Genova, Genova 16132, Italy
- Nuclear Medicine, IRCCS Ospedale Policlinico San Martino, Genova 16132, Italy
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Sood A, Kishan AU, Evans CP, Feng FY, Morgan TM, Murphy DG, Padhani AR, Pinto P, Van der Poel HG, Tilki D, Briganti A, Abdollah F. The Impact of Positron Emission Tomography Imaging and Tumor Molecular Profiling on Risk Stratification, Treatment Choice, and Oncological Outcomes of Patients with Primary or Relapsed Prostate Cancer: An International Collaborative Review of the Existing Literature. Eur Urol Oncol 2024; 7:27-43. [PMID: 37423774 DOI: 10.1016/j.euo.2023.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 05/06/2023] [Accepted: 06/07/2023] [Indexed: 07/11/2023]
Abstract
CONTEXT The clinical introduction of next-generation imaging methods and molecular biomarkers ("radiogenomics") has revolutionized the field of prostate cancer (PCa). While the clinical validity of these tests has thoroughly been vetted, their clinical utility remains a matter of investigation. OBJECTIVE To systematically review the evidence to date on the impact of positron emission tomography (PET) imaging and tissue-based prognostic biomarkers, including Decipher, Prolaris, and Oncotype Dx, on the risk stratification, treatment choice, and oncological outcomes of men with newly diagnosed PCa or those with biochemical failure (BCF). EVIDENCE ACQUISITION We performed a quantitative systematic review of the literature using the MEDLINE, EMBASE, and Web of Science databases (2010-2022) following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement guidelines. The validated Quality Assessment of Diagnostic Accuracy Studies 2 scoring system was used to assess the risk of bias. EVIDENCE SYNTHESIS A total of 148 studies (130 on PET and 18 on biomarkers) were included. In the primary PCa setting, prostate-specific membrane antigen (PSMA) PET imaging was not useful in improving T staging, moderately useful in improving N staging, but consistently useful in improving M staging in patients with National Comprehensive Cancer Network (NCCN) unfavorable intermediate- to very-high-risk PCa. Its use led to a management change in 20-30% of patients. However, the effect of these treatment changes on survival outcomes was not clear. Similarly, biomarkers in the pretherapy primary PCa setting increased and decreased the risk, respectively, in 7-30% and 32-36% of NCCN low-risk and 31-65% and 4-15% of NCCN favorable intermediate-risk patients being considered for active surveillance. A change in management was noted in up to 65% of patients, with the change being in line with the molecular risk-based reclassification, but again, the impact of these changes on survival outcomes remained unclear. Notably, in the postsurgical primary PCa setting, biomarker-guided adjuvant radiation therapy (RT) was associated with improved oncological control: Δ↓ 2-yr BCF by 22% (level 2b). In the BCF setting, the data were more mature. PSMA PET was consistently useful in improving disease localization-Δ↑ detection for T, N, and M staging was 13-32%, 19-58%, and 9-29%, respectively. Between 29% and 73% of patients had a change in management. Most importantly, these management changes were associated with improved survival outcomes in three trials: Δ↑ 4-yr disease-free survival by 24.3%, Δ↑ 6-mo metastasis-free survival (MFS) by 46.7%, and Δ↑ androgen deprivation therapy-free survival by 8 mo in patients who received PET-concordant RT (level 1b-2b). Biomarker testing in these patients also appeared to be helpful in risk stratifying and guiding the use of early salvage RT (sRT) and concomitant hormonal therapy. Patients with high-genomic-risk scores benefitted from treatment intensification: Δ↑ 8-yr MFS by 20% with the use of early sRT and Δ↑ 12-yr MFS by 11.2% with the use of hormonal therapy alongside early sRT, while low-genomic-risk score patients did equally well with initial conservative management (level 3). CONCLUSIONS Both PSMA PET imaging and tumor molecular profiling provide actionable information in the management of men with primary PCa and those with BCF. Emerging data suggest that radiogenomics-guided treatments translate into direct survival benefits for patients, however, additional prospective data are awaited. PATIENT SUMMARY In this review, we evaluated the utility of prostate-specific membrane antigen positron emission tomography and tumor molecular profiling in guiding the care of men with prostate cancer (PCa). We found that these tests augmented risk stratification, altered management, and improved cancer control in men with a new diagnosis of PCa or for those experiencing a relapse.
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Affiliation(s)
- Akshay Sood
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Urology, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Amar U Kishan
- Department of Radiation Oncology and Urology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Christopher P Evans
- Department of Urologic Surgery, University of California Davis, Sacramento, CA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Declan G Murphy
- Department of Genitourinary Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Victoria, Australia
| | - Anwar R Padhani
- Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, Middlesex, UK
| | - Peter Pinto
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Henk G Van der Poel
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Koc University Hospital, Istanbul, Turkey
| | - Alberto Briganti
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Firas Abdollah
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.
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Wang Y, Tang Y, Gao X, Gan Y, Hu S, Chen MF, Cai Y. Optimization of prostate cancer patient lymph node staging via the integration of neutrophil-lymphocyte ratios, platelet-lymphocyte ratios, and 68 Ga-PSMA-PET-derived SUVmax values. Prostate 2022; 82:1415-1421. [PMID: 35860907 DOI: 10.1002/pros.24415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/12/2022] [Accepted: 07/04/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND At present, standardized parameters for quantitatively evaluating 68 Ga-PSMA-PET/CT outcomes when diagnosing lymph node metastasis in prostate cancer patients are lacking. Inflammatory hematological biomarkers offer value as robust predictors of certain cancer-related outcomes. The present study was thus developed to explore approaches to improving the utility of 68 Ga-PSMA-PET/CT for diagnosing lymph node metastasis through the combined evaluation of inflammatory hematological markers in prostate cancer patients. METHODS Pretreatment patient details including age, initial TPSA levels, hematological findings, biopsy pathology results (Gleason score and ISUP grouping), radical pathology results, and imaging details were collected. Optimal cutoff values for each predictor then being determined based upon Youden's index, with univariate and multivariate analyses were then used to identify independent predictors of lymph node metastasis and used to construct a nomogram. RESULT Independent predictors of lymph node metastasis in this patient cohort included SUVmax (odds ratio [OR]: 30.549, 95% confidence interval [CI]: 10.855-85.973, p < 0.001), neutrophil-lymphocyte ratio (OR:8.221, 95%CI: 1.335-50.614, p = 0.023), platelet-lymphocyte ratio (OR:8.221, 95% CI: 1.335-50.614, p = 0.023), initial TPSA (OR:2.761, 95% CI: 1.132-6.733, p = 0.026), and clinical T-stage (T3 vs. T2, OR:11.332, 95% CI:3.929-32.681, p < 0.001; T4 vs. T2, OR:9.101, 95% CI:1.962-42.213, p = 0.005), with corresponding optimal cutoff values of 2.3 (area under the curve [AUC]: 0.873, sensitivity: 0.736, specificity: 0.902), 1.72 (AUC: 0.558, sensitivity: 0.529, specificity: 0.643), 83.305 (AUC: 0.651, sensitivity: 0.299, specificity: 0.979), and 21.875 (AUC: 0.672, sensitivity: 0.736, specificity: 0.601). Subsequent nomogram construction was associated with good predictive ability, with a C-index of 0.887(95% CI: 0.793-0.981) and an AUC of 0.924 (95% CI: 0.882-0.965). CONCLUSION SUVmax, the neutrophil-lymphocyte ratio, the platelet-lymphocyte ratio, initial TPSA, and clinical T-stage represent valuable independent predictors of lymph node metastasis in prostate cancer patients, offering an opportunity to further optimize lymph node staging for these patients.
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Affiliation(s)
| | - Yongxiang Tang
- Department of Nuclear Medicine, Disorders of Prostate Cancer Multidisciplinary Team, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha City, Hunan Province, China
| | - Xiaomei Gao
- Department of Pathology, Disorders of Prostate Cancer Multidisciplinary Team, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha City, Hunan Province, China
| | - Yu Gan
- Department of Urology, Disorders of Prostate Cancer Multidisciplinary Team, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha City, Hunan Province, China
| | - Shuo Hu
- Department of Nuclear Medicine, Disorders of Prostate Cancer Multidisciplinary Team, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha City, Hunan Province, China
| | - Min-Feng Chen
- Department of Urology, Disorders of Prostate Cancer Multidisciplinary Team, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha City, Hunan Province, China
| | - Yi Cai
- Department of Urology, Disorders of Prostate Cancer Multidisciplinary Team, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha City, Hunan Province, China
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Hu C, Dong L, Xue W, Pienta KJ. Prostate-Specific Membrane Antigen-Based PET Brings New Insights into the Management of Prostate Cancer. PET Clin 2022; 17:555-564. [PMID: 36153235 DOI: 10.1016/j.cpet.2022.07.001] [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: 10/14/2022]
Abstract
Prostate cancer (PCa) is the third most common cancer diagnosed in the world. Since its first identification in 1987 and its first molecular cloning in 1993, prostate-specific membrane antigen (PSMA) has been developed as a theragnostic imaging biomarker and therapeutic agent for PCa. For metastatic castration-resistant PCa, PSMA-based PET imaging can be applied to the monitoring of disease and response assessment with PSMA-based therapeutics. This novel imaging modality is bringing new insights into diagnosis, stratification, and clinical decision-making and treatment.
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Affiliation(s)
- Cong Hu
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai 200127, China
| | - Liang Dong
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai 200127, China
| | - Wei Xue
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai 200127, China
| | - Kenneth J Pienta
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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Prostate specific membrane antigen positron emission tomography in primary prostate cancer diagnosis: First-line imaging is afoot. Cancer Lett 2022; 548:215883. [PMID: 36027998 DOI: 10.1016/j.canlet.2022.215883] [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: 07/23/2022] [Accepted: 08/11/2022] [Indexed: 11/23/2022]
Abstract
Prostate specific membrane antigen positron emission tomography (PSMA PET) is an excellent molecular imaging technique for prostate cancer. Currently, PSMA PET for patients with primary prostate cancer is supplementary to conventional imaging techniques, according to guidelines. This supplementary function of PSMA PET is due to a lack of systematic review of its strengths, limitations, and potential development direction. Thus, we review PSMA ligands, detection, T, N, and M staging, treatment management, and false results of PSMA PET in clinical studies. We also discuss the strengths and challenges of PSMA PET. PSMA PET can greatly increase the detection rate of prostate cancer and accuracy of T/N/M staging, which facilitates more appropriate treatment for primary prostate cancer. Lastly, we propose that PSMA PET could become the first-line imaging modality for primary prostate cancer, and we describe its potential expanded application.
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Huebner N, Rasul S, Baltzer P, Clauser P, Hermann Grubmüller K, Mitterhauser M, Hacker M, Heidenreich A, Rajwa P, Fajkovic H, Shariat SF, Grubmüller B. Feasibility and Optimal Time Point of [68Ga]Gallium-labeled Prostate-specific Membrane Antigen Ligand Positron Emission Tomography Imaging in Patients Undergoing Cytoreductive Surgery After Systemic Therapy for Primary Oligometastatic Prostate Cancer: Implications for Patient Selection and Extent of Surgery. EUR UROL SUPPL 2022; 40:117-124. [PMID: 35638090 PMCID: PMC9142741 DOI: 10.1016/j.euros.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background Prostate-specific membrane antigen (PSMA) targeted molecular imaging using positron emission tomography (PET) has significantly improved the diagnosis and treatment of prostate cancer (PCA). Objective To assess the feasibility and compare the diagnostic accuracy of [68Ga]Ga-PSMA-11 PET images taken at baseline, before the initiation of systemic treatment and preoperative images, using histopathology after cytoreductive surgery as reference. Design, setting, and participants We identified 20 patients in our prospectively maintained database with primary oligometastatic PCA who underwent cytoreductive radical prostatectomy and superextended pelvic lymph node dissection after systemic therapy, who had baseline and preoperative [68Ga]Ga-PSMA-11 PET imaging available. Outcome measurements and statistical analysis We performed a region-based analysis to determine the diagnostic accuracy of imaging, using pathology as a reference. Regions were predefined as prostate, internal iliac left/right, obturator left/right, external iliac left/right, common iliac left/right, and presacral. Results and limitations Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and diagnostic effectiveness were, respectively, 95.65%, 78.22%, 98.39%, 57.89%, and 83.00% for baseline [68Ga]Ga-PSMA-11 PET, compared to 56.52%, 98.05%, 88.30%, 89.66%, and 88.50% for preoperative [68Ga]Ga-PSMA-11 PET. On a receiver operating characteristic analysis, the diagnostic accuracy of baseline [68Ga]Ga-PSMA-11 PET with an area under the curve (AUC) of 0.87 (95% confidence interval [CI] 0.83–0.92) was significantly better than that of preoperative [68Ga]Ga-PSMA-11 PET after systemic therapy with an AUC of 0.77 (95% CI 0.70–0.85, p = 0.01). Conclusions Baseline imaging, [68Ga]Ga-PSMA-11 PET has significantly better diagnostic accuracy, sensitivity, and NPV than images obtained preoperatively, in systemically pretreated patients. If a patient is suitable for local treatment and complete resection of the residual tumor is intended, [68Ga]Ga-PSMA-11 PET images taken prior to systemic therapy are significantly more accurate in selecting the relevant lymph nodes for resection. Patient summary We found that prostate-specific membrane antigen positron emission tomography (PSMA-PET) imaging used early, before hormonal therapy or chemotherapy, provides more accurate information about the spread of the disease, than if used immediately before surgery but after hormonal therapy or chemotherapy. Early use of PSMA-PET has the potential to improve therapy also at later stages of the disease.
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Accuracy of 68Ga-PSMA PET/CT for lymph node and bone primary staging in prostate cancer. Urol Oncol 2021; 40:104.e17-104.e21. [PMID: 34911650 DOI: 10.1016/j.urolonc.2021.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/04/2021] [Accepted: 11/06/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE The aim of this study is to assess the accuracy of the 68Ga-PSMA PET/CT for lymph nodes and bones in the primary stage of prostate cancer. METHODS A total of 126 patients who were submitted to 68Ga-PSMA PET/CT from January 2016 to February 2019 for prostate cancer staging, detection of clinically significant lesions or active surveillance were included in this study. All studies were read by 2 experienced physicians (a nuclear physician and a radiologist). The reports were made in consensus and used by one of the authors to classify the exam in positive or negative. We evaluated presence of abnormal uptake in the prostate, lymph nodes, and bone. The reference standards were histopathological confirmation, confirmatory imaging exams and/or clinical follow-up showing lesion(s) regression after specific treatment, or typical osseous metastatic lesions and highly increased PSA levels. RESULTS Measurement of diagnostic performance indicated a sensitivity, specificity and accuracy of 75%, 96.3%, and 90.8%, respectively, for lymph node involvement, and 90.9%, 50%, and 76.5%, respectively for metastatic bone lesions. CONCLUSION This study showed high specificity and accuracy of 68Ga-PSMA PET/CT for lymph node and bone involvement in prostate cancer staging.
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Ling SW, de Jong AC, Schoots IG, Nasserinejad K, Busstra MB, van der Veldt AAM, Brabander T. Comparison of 68Ga-labeled Prostate-specific Membrane Antigen Ligand Positron Emission Tomography/Magnetic Resonance Imaging and Positron Emission Tomography/Computed Tomography for Primary Staging of Prostate Cancer: A Systematic Review and Meta-analysis. EUR UROL SUPPL 2021; 33:61-71. [PMID: 34632423 PMCID: PMC8488242 DOI: 10.1016/j.euros.2021.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 11/25/2022] Open
Abstract
Context In December 2020, the US Food and Drug Administration approved a 68Ga-labeled prostate-specific membrane antigen ligand (68Ga-PSMA-11) for positron emission tomography (PET) in patients with suspected prostate cancer (PCa) metastasis who are candidates for initial definitive therapy. 68Ga-PSMA PET is increasingly performed for these patients and is usually combined with computed tomography (CT). In recent years, 68Ga-PSMA PET has been combined with high-resolution magnetic resonance imaging (MRI), which is beneficial for T staging and may further enhance the staging of primary PCa. Objective To compare the diagnostic accuracy of 68Ga-PSMA PET/MRI with 68Ga-PSMA PET/CT for staging of primary PCa. Evidence acquisition A comprehensive literature search was performed using Embase, PubMed/Medline, Web of Science, Cochrane Library, and Google Scholar up to June 24, 2021 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed using the QUADAS-2 tool. Evidence synthesis The search identified 2632 articles, of which 27 were included. The diagnostic accuracy of 68Ga-PSMA PET/MRI, measured as the pooled natural logarithm of diagnostic odds ratio (lnDOR), was 2.27 (95% confidence interval [CI] 1.21–3.32) for detection of extracapsular extension (ECE), 3.50 (95% CI 2.14–4.86) for seminal vesicle invasion (SVI), and 4.73 (95% CI 2.93–6.52) for lymph node metastasis (LNM). For 68Ga-PSMA PET/CT, the analysis showed lnDOR of 2.45 (95% CI 0.75–4.14), 2.94 (95% CI 2.26–3.63), and 2.42 (95% CI 2.07–2.78) for detection of ECE, SVI, and LNM, respectively. The overall risk of bias and applicability concerns were assessed as moderate and low, respectively. Conclusions 68Ga-PSMA PET/MRI shows high diagnostic accuracy equivalent to that of 68Ga-PSMA PET/CT for detection of ECE, SVI, and LNM in staging of PCa. There is an urgent need for direct comparison of the two diagnostic tests in future research. Patient summary The use of radioactively labeled molecules that bind to prostate-specific membrane antigen (68Ga-PSMA) for positron emission tomography (PET) scans combined with either computed tomography (CT) or magnetic resonance imaging (MRI) is increasing for prostate cancer diagnosis. There is a need for direct comparison of the two tests to demonstrate the benefit of 68Ga-PSMA PET/MRI for determining tumor stage in prostate cancer. Take Home Message After the recent US Food and Drug Administration approval of 68Ga-labeled prostate-specific membrane antigen ligand (68Ga-PSMA) positron emission tomography (PET) for staging of primary prostate cancer (PCa), it is expected that the use of this imaging modality will increase rapidly. Our review of the literature shows that 68Ga-PSMA PET/magnetic resonance imaging has high diagnostic accuracy equivalent to that of 68Ga-PSMA PET/computed tomography in primary PCa staging. There is an urgent need for direct head-to-head comparison of the two diagnostic tests in future research.
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Affiliation(s)
- Sui Wai Ling
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Anouk C de Jong
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.,Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Astrid A M van der Veldt
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.,Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Tessa Brabander
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
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Stabile A, Pellegrino A, Mazzone E, Cannoletta D, de Angelis M, Barletta F, Scuderi S, Cucchiara V, Gandaglia G, Raggi D, Necchi A, Karakiewicz P, Montorsi F, Briganti A. Can Negative Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography Avoid the Need for Pelvic Lymph Node Dissection in Newly Diagnosed Prostate Cancer Patients? A Systematic Review and Meta-analysis with Backup Histology as Reference Standard. Eur Urol Oncol 2021; 5:1-17. [PMID: 34538770 DOI: 10.1016/j.euo.2021.08.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/05/2021] [Accepted: 08/31/2021] [Indexed: 01/06/2023]
Abstract
CONTEXT The role of positron emission tomography/computed tomography (PET/CT) with prostate-specific membrane antigen (PSMA) in the primary staging for patients with prostate cancer (PCa) is still debated. OBJECTIVE To analyze published studies reporting the accuracy of PSMA PET/CT for detecting lymph node invasion (LNI) at pelvic lymph node dissection (PLND). EVIDENCE ACQUISITION A search of PubMed/MEDLINE, Cochrane library's Central, EMBASE and Scopus databases, from inception to May 2021, was conducted. The primary outcome was to evaluate the sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of PSMA PET/CT in detecting LNI on a per-patient level. As a secondary outcome, NPV of PET PSMA was tested on a per-node-level analysis. Detection rates were pooled using random-effect models. Preplanned subgroup analyses tested the diagnostic accuracy after stratification for the preoperative risk group. PPV and NPV variation over LNI prevalence was evaluated. Only studies including extended PLND (ePLND) as the reference standard test were included. EVIDENCE SYNTHESIS Twenty-seven studies, with a total of 2832 participants, were included in quantitative synthesis. The sensitivity, specificity, PPV, and NPV of PSMA PET/CT for LNI were, respectively, 58% (95% confidence interval [CI] 50-66%), 95% (95% CI 93-97%), 79% (95% CI 72-85%), and 87% (95% CI 84-89%), with overall moderate heterogeneity between studies. At bivariate analysis, the diagnostic accuracy of PSMA PET/CT estimated through summary receiver operating characteristic-derived area under the curve was 84% (95% CI 81-87%). On a per-node level, NPV of PET PSMA was 97% (95% CI 96-99%). At subgroup analyses, according to preoperative risk groups, sensitivity, specificity, PPV, and NPV were 51%, 93%, 73%, and 81%, respectively, in high-risk patients. Over the LNI prevalence range of 5-40%, PPV increased from 59% to 91%, while NPV decreased from 99% to 84%. CONCLUSIONS PSMA PET/CT scan provides promising accuracy in the field of primary nodal staging for PCa. The high NPV in men with a lower risk of LNI might be clinically useful to reduce the number of unnecessary PLND procedures performed. Conversely, in high-risk patients, negative PSMA PET/CT cannot replace staging ePLND. PATIENT SUMMARY In this systematic review and meta-analysis, we demonstrated that prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) scan may optimize the primary nodal staging and surgical management of prostate cancer patients candidate to radical prostatectomy. The high negative predictive value in men with a lower risk of lymph node invasion might be clinically useful for reducing the number of useless pelvic lymph node dissection (PLND) procedures performed. Conversely, in high-risk patients, negative PSMA PET/CT cannot allow avoiding of PLND.
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Affiliation(s)
- Armando Stabile
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Antony Pellegrino
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Elio Mazzone
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Donato Cannoletta
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Mario de Angelis
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Barletta
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Simone Scuderi
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Vito Cucchiara
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giorgio Gandaglia
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Daniele Raggi
- Department of Oncology, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Necchi
- Department of Oncology, Vita-Salute San Raffaele University, Milan, Italy
| | - Pierre Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Francesco Montorsi
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Briganti
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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Szigeti F, Schweighofer-Zwink G, Meissnitzer M, Hauser-Kronberger C, Hitzl W, Kunit T, Forstner R, Pirich C, Beheshti M. Incremental Impact of [ 68 Ga]Ga-PSMA-11 PET/CT in Primary N and M Staging of Prostate Cancer Prior to Curative-Intent Surgery: a Prospective Clinical Trial in Comparison with mpMRI. Mol Imaging Biol 2021; 24:50-59. [PMID: 34519966 PMCID: PMC8760214 DOI: 10.1007/s11307-021-01650-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/29/2021] [Accepted: 09/01/2021] [Indexed: 01/21/2023]
Abstract
Purpose The main objective of this prospective study was to assess the value of gallium-68 prostate-specific membrane antigen ([68 Ga]Ga-PSMA-11) positron emission tomography/computed tomography (PET/CT) in primary N and M staging of intermediate- and high-risk prostate cancer (PCa) patients before planned curative-intent radical prostatectomy (RPE) and extended pelvic lymph node dissection (ePLND). The second objective was to compare the [68 Ga]Ga-PSMA-11 PET/CT findings with standard of care pelvic multi-parametric magnetic resonance imaging (mpMRI) in the detection of locoregional lymph node metastases and intraprostatic prostate cancer. Procedures A total of 81 patients (mean age: 64.5 years, baseline mean trigger PSA (tPSA) 15.4 ng/ml, ± 15.9) with biopsy proven PCa (24 intermediate- and 57 high risk) scheduled for RPE and ePLND were enrolled in this prospective study. In 52 patients [68 Ga]Ga-PSMA-11 PET/CT, pelvic mpMRI, and RPE with ePLND have been performed. Clinical risk stratification and related biomarkers as well as Gleason score (GS) were recorded. The location of the index lesion (IL) was documented systematically for each modality using a standardized segmentation of the prostate in six segments. Distant bone and lymph node metastasis detected by [68 Ga]Ga-PSMA-11 PET/CT were documented. [68 Ga]Ga-PSMA-11 PET/CT findings were correlated with results of mpMRI and histopathology. A consensus of imaging, clinical and/or follow-up findings were used for determining the distant metastases, which were not verified by histopathology. Results In the patient cohort who underwent RPE, [68 Ga]Ga-PSMA-11 PET/CT and mpMRI detected the IL in 86.5% and 98.1% of the patients, respectively. The median of the maximum standardized uptake value (SUVmax) in the intraprostatic IL was 12 (range, 4.7–67.8). Intraprostatic IL of the high-risk patients showed significantly higher SUVmax than those in patients with intermediate risk for distant metastases (n = 48; median: 17.84 vs. 8.77; p = 0.02). In total 729 LN were removed by ePLND in 48 patients. The histopathology verified 26 pelvic lymph node metastases (pLNM) in 20.8% (10/48) of the patients, which have been correctly identified in 60% of the patients on [68 Ga]Ga-PSMA-11 PET/CT, and in 50% on mpMRI. All but one pLNM had a maximum diameter below 10 mm. Bone metastases (BM) and distant LNM (dLNM) were found in 17.3% of the patients on [68 Ga]Ga-PSMA-11 PET/CT imaging. 39.0% of the [68 Ga]Ga-PSMA-11 PET-positive BM showed no suspicious morphological correlation on CT. Conclusion [68 Ga]Ga-PSMA-11 PET/CT shows high diagnostic performance for N and M staging of patients with intermediate- and high-risk prostate cancer and seems to be superior to pelvic mpMRI in the detection of locoregional lymph node metastases. A significant correlation was found between SUVmax of the intraprostatic index lesion and risk stratification based on tPSA level and GS. The results of this study emphasize again on the role of metabolic molecular imaging using specific tracers in selected patients, leading to tailored therapy approach. Supplementary Information The online version contains supplementary material available at 10.1007/s11307-021-01650-9.
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Affiliation(s)
- Florian Szigeti
- Salzburg University of Applied Sciences, Radiation Technology Degree Program, Salzburg, Austria
| | - Gregor Schweighofer-Zwink
- Division of Molecular Imaging and Theranostics, Department of Nuclear Medicine and Endocrinology, University Hospital, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Matthias Meissnitzer
- Department of Radiology, University Hospital, Paracelsus Medical University, Salzburg, Austria
| | | | - Wolfgang Hitzl
- Research Office (Biostatistics), Paracelsus Medical University, 5020, Salzburg, Austria.,Department of Ophthalmology and Optometry, University Hospital, Paracelsus Medical University, 5020, Salzburg, Austria.,Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, 5020, Salzburg, Austria
| | - Thomas Kunit
- Department of Urology and Andrology, University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Rosemarie Forstner
- Department of Radiology, University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Christian Pirich
- Division of Molecular Imaging and Theranostics, Department of Nuclear Medicine and Endocrinology, University Hospital, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Mohsen Beheshti
- Division of Molecular Imaging and Theranostics, Department of Nuclear Medicine and Endocrinology, University Hospital, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria.
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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.
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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;
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Hernes E, Revheim ME, Hole KH, Tulipan AJ, Strømme H, Lilleby W, Seierstad T. Prostate-Specific Membrane Antigen PET for Assessment of Primary and Recurrent Prostate Cancer with Histopathology as Reference Standard: A Systematic Review and Meta-Analysis. PET Clin 2021; 16:147-165. [PMID: 33648661 DOI: 10.1016/j.cpet.2020.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Prostate-specific membrane antigen PET is a promising diagnostic tool in prostate cancer. The gold standard for the detection of prostate tumor and lymph node metastases is histopathology. The aim of the present review was to investigate accuracy measures of 68Ga/18F-labeled prostate-specific membrane antigen PET tracers in primary and recurrent prostate cancer with systematic sector-based histopathology as the reference standard. A systematic literature search was performed and 34 studies were included. Overall, prostate-specific membrane antigen PET showed high specificity, but variable sensitivity to localize known prostate cancer and detect pelvic lymph node metastases.
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Affiliation(s)
- Eivor Hernes
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway.
| | - Mona-Elisabeth Revheim
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Knut Håkon Hole
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Andreas Julius Tulipan
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Hilde Strømme
- Library of Medicine and Science, University of Oslo, Sognsvannsveien 20, 0372 Oslo, Norway
| | - Wolfgang Lilleby
- Department of Oncology, Oslo University Hospital, P.O. Box 4953 Nydalen, 0424 Oslo, Norway
| | - Therese Seierstad
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway
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Prostate-specific membrane antigen PET/computed tomography for staging prostate cancer. Curr Opin Urol 2020; 30:628-634. [PMID: 32701720 DOI: 10.1097/mou.0000000000000799] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Molecular imaging with PET/CT targeting the prostate-specific membrane antigen (PSMA) receptor is increasingly utilized in men with prostate cancer (PCa), with clinical indications now expanding beyond biochemical recurrence. PSMA PET/CT often detects sub-centimetre size pathologic nodes and low-volume bone marrow disease that are occult on conventional imaging when the lesion does not cause sclerosis or osteoblastic reaction in surrounding bone. This review focuses on recent evidence for PSMA PET/CT in initial disease staging. RECENT FINDINGS Several recent studies including a large randomized trial have evaluated the clinical impact of PSMA PET/CT in initial staging of PCa. PSMA PET/CT is more sensitive and accurate than the conventional imaging standard of CT and bone scan. Change in treatment plan or modality of therapy occurs frequently when PSMA PET/CT forms part of the diagnostic algorithm. Hybrid PET/MRI also has potential utility, particularly in evaluating pelvic disease, but evidence base remains very limited. SUMMARY PSMA PET/CT has emerged as a new standard in primary staging of PCa. Reimbursement by national funding bodies and incorporation into international clinical guidelines is anticipated within the next few years.
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