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Wong LM, Sutherland T, Perry E, Tran V, Spelman T, Corcoran N, Lawrentschuk N, Woo H, Lenaghan D, Buchan N, Bax K, Symons J, Saeed Goolam A, Chalasani V, Hegarty J, Thomas L, Christov A, Ng M, Khanani H, Lee SF, Taubman K, Tarlinton L. Fluorine-18-labelled Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography or Magnetic Resonance Imaging to Diagnose and Localise Prostate Cancer. A Prospective Single-arm Paired Comparison (PEDAL). Eur Urol Oncol 2024:S2588-9311(24)00026-9. [PMID: 38281891 DOI: 10.1016/j.euo.2024.01.002] [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: 10/19/2023] [Revised: 12/03/2023] [Accepted: 01/05/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND AND OBJECTIVE Multiparametric magnetic resonance imaging (mpMRI) of the prostate is used for prostate cancer diagnosis. However, mpMRI has lower sensitivity for small tumours. Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT) offers increased sensitivity over conventional imaging. This study aims to determine whether the diagnostic accuracy of 18F-DCFPyL PSMA-PET/CT was superior to that of mpMRI for detecting prostate cancer (PCa) at biopsy. METHODS Between 2020 and 2021, a prospective multicentre single-arm phase 3 imaging trial enrolled patients with clinical suspicion for PCa to have both mpMRI and PSMA-PET/CT (thorax to thigh), with reviewers blinded to the results of other imaging. Multiparametric MRI was considered positive for Prostate Imaging Reporting and Data System (PIRADS) 3-5. PSMA-PET/CT was assessed quantitatively (positive maximum standardised uptake value [SUVmax] >7) and qualitatively (five-point lexicon of certainty). Patients underwent targeted and systematic biopsy, with the technique at the discretion of the treating urologist. Clinically significant PCa (csPCa) was defined as International Society of Urological Pathology grade group (GG) ≥2. The primary outcome was the diagnostic accuracy for detecting PCa, reported as sensitivity, specificity, negative predictive value (NPV), and area under the curve (AUC) of the receiver operating curve. The secondary endpoints included a comparison of the diagnostic accuracy for detecting csPCa, assessing gains in combining PMSA-PET/CT with mpMRI to mpMRI alone. KEY FINDINGS AND LIMITATIONS Of the 236 patients completing both mpMRI and PSMA-PET/CT, 184 (76.7%) had biopsy. Biopsy histology was benign (n = 73), GG 1 (n = 27), and GG ≥2 (n = 84). The diagnostic accuracy of mpMRI for detecting PCa (AUC 0.76; 95% confidence interval [CI] 0.69, 0.82) was higher than that of PSMA-PET/CT (AUC 0.63; 95% CI 0.56, 0.70, p = 0.03). The diagnostic accuracy of mpMRI for detecting csPCa (AUC 0.72; 95% CI 0.67, 0.78) was higher than that of PSMA-PET/CT (AUC 0.62; 95% CI 0.55, 0.69) but not statistically significant (p = 0.27). A combination of PSMA-PET/CT and mpMRI showed excellent sensitivity (98.8%, 95% CI 93.5%, 100%) and NPV (96%, 95% CI 79.6%, 99.9%) over mpMRI alone (86.9% and 80.7%, respectively, p = 0.01). Thirty-two patients (13.6%) had metastatic disease. They tended to be older (68.4 vs 65.1 yr, p = 0.023), and have higher prostate-specific antigen (PSA; median PSA 9.6 vs 6.2ng/ml, p < 0.001) and abnormal prostate on digital rectal examination (78.2% vs 44.1%, p < 0.001). CONCLUSIONS AND CLINICAL IMPLICATIONS Multiparametric MRI had superior diagnostic accuracy to PSMA-PET/CT for detecting PCa, though the difference is not significant in case of csPCa detection. A combination of mpMRI and PSMA-PET/CT showed improved sensitivity and NPV. PSMA-PET/CT could be considered for diagnostic use in patients unable to have mpMRI or those with concerning clinical features but negative mpMRI. PATIENT SUMMARY In this trial, we compared the ability of 18F-labelled prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT) with that of multiparametric magnetic resonance imaging (mpMRI) to diagnose prostate cancer by biopsy in a prostate-specific antigen screening population. We found that MRI was superior to PSMA to diagnose prostate cancer, though there was no difference in ability to diagnose clinically significant prostate cancer. PSMA-PET/CT could be considered for diagnostic use in patients unable to have mpMRI or those with concerning clinical features but negative mpMRI. Combining MRI with PSMA-PET increases the negative predictive value over MRI alone and may help men avoid invasive prostate biopsy.
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Affiliation(s)
- Lih-Ming Wong
- Department of Urology, St Vincent's Health, Melbourne, Australia; Department of Surgery, University of Melbourne, Melbourne, Australia.
| | - Tom Sutherland
- Department of Medical Imaging, St Vincent's Health, Melbourne, Australia; Faculty of Medicine, University of Melbourne, Melbourne, Australia
| | - Elisa Perry
- Pacific Radiology, Christchurch, Canterbury, New Zealand
| | - Vy Tran
- Department of Urology, St Vincent's Health, Melbourne, Australia; Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Tim Spelman
- Department of Surgery, University of Melbourne, Melbourne, Australia; Burnet Institute, Melbourne, Australia
| | - Niall Corcoran
- Department of Surgery, University of Melbourne, Melbourne, Australia; Department of Urology, Melbourne Health, Melbourne, Australia
| | - Nathan Lawrentschuk
- Department of Surgery, University of Melbourne, Melbourne, Australia; Department of Urology, Melbourne Health, Melbourne, Australia; EJ Whitten Prostate Cancer Research Centre at Epworth Healthcare, Melbourne, Australia
| | - Henry Woo
- Department of Urology, Sydney Adventist Hospital, New South Wales, Australia; Sydney Adventist Northshore Prostate Centre of Excellence, Sydney Adventist Hospital, New South Wales, Australia
| | - Daniel Lenaghan
- Department of Urology, St Vincent's Health, Melbourne, Australia; Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Nicholas Buchan
- Christchurch Public Hospital, Urology Associates, Christchurch, New Zealand; Canterbury Urology Research Trust Board, Christchurch, New Zealand
| | - Kevin Bax
- Christchurch Public Hospital, Urology Associates, Christchurch, New Zealand; Canterbury Urology Research Trust Board, Christchurch, New Zealand
| | - James Symons
- Department of Urology, Sydney Adventist Hospital, New South Wales, Australia
| | - Ahmed Saeed Goolam
- Department of Urology, Sydney Adventist Hospital, New South Wales, Australia
| | - Venu Chalasani
- Department of Urology, Sydney Adventist Hospital, New South Wales, Australia
| | - Justin Hegarty
- Pacific Radiology, Christchurch, Canterbury, New Zealand
| | - Lauren Thomas
- Department of Medical Imaging, St Vincent's Health, Melbourne, Australia; Faculty of Medicine, University of Melbourne, Melbourne, Australia
| | - Alexandar Christov
- Department of Urology, St Vincent's Health, Melbourne, Australia; Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Michael Ng
- GenesisCare, St Vincent's, Melbourne, Australia
| | - Hadia Khanani
- Sydney Adventist Northshore Prostate Centre of Excellence, Sydney Adventist Hospital, New South Wales, Australia
| | - Su-Faye Lee
- Department of Medical Imaging, St Vincent's Health, Melbourne, Australia; Faculty of Medicine, University of Melbourne, Melbourne, Australia
| | - Kim Taubman
- Department of Medical Imaging, St Vincent's Health, Melbourne, Australia; Faculty of Medicine, University of Melbourne, Melbourne, Australia
| | - Lisa Tarlinton
- Sydney Adventist Northshore Prostate Centre of Excellence, Sydney Adventist Hospital, New South Wales, Australia
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