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Dullea A, O'Sullivan L, O'Brien KK, Carrigan M, Ahern S, McGarry M, Harrington P, Walsh KA, Smith SM, Ryan M. Diagnostic Accuracy of 18F-Prostate Specific Membrane Antigen (PSMA) PET/CT Radiotracers in Staging and Restaging of Patients With High-Risk Prostate Cancer or Biochemical Recurrence: An Overview of Reviews. Semin Nucl Med 2024:S0001-2998(24)00044-8. [PMID: 38906759 DOI: 10.1053/j.semnuclmed.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/03/2024] [Indexed: 06/23/2024]
Abstract
The aim of this overview was to consolidate existing evidence syntheses and provide a comprehensive overview of the evidence for 18F-prostate specific membrane antigen (PSMA) PET/CT in the staging of high-risk prostate cancer and restaging after biochemical recurrence. An overview of reviews was performed and reported in line with the preferred reporting items for overview of reviews (PRIOR) statement and synthesis without meta-analysis (SWiM) reporting guidelines. A comprehensive database and grey literature search were conducted up to July 18, 2023. Systematic reviews were assessed using the risk of bias in systematic reviews (ROBIS) tool. The certainty of the evidence was assessed using grading of recommendations, assessment, development and evaluations (GRADE). 11 systematic reviews were identified; 10 were at high or unclear risk of bias. Evidence reported on a per-patient, per-lymph node, and per-lesion basis for sensitivity, specificity and overall accuracy was identified. There was a lack of data on dose, adverse events and evidence directly comparing 18F-PSMA PET/CT to other imaging modalities. Evidence with moderate to very low certainty indicated high sensitivity, specificity and accuracy of 18F-PSMA PET/CT in patients with high-risk prostate cancer and biochemical recurrence. There was considerably lower certainty evidence and greater variability in effect estimates for outcomes for the combined intermediate/high-risk cohort. While evidence gaps remain for some outcomes, and most systematic reviews were at high or unclear risk of bias, the current evidence base is broadly supportive of 18F-PSMA PET/CT imaging in the staging and restaging of patients with high-risk prostate cancer and biochemical recurrence.
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Affiliation(s)
- Andrew Dullea
- Discipline of Public Health & Primary Care, School of Medicine, Trinity College, Dublin, Ireland; Health Technology Assessment Directorate, Health Information and Quality Authority, Cork, Ireland.
| | - Lydia O'Sullivan
- Health Technology Assessment Directorate, Health Information and Quality Authority, Cork, Ireland; Health Research Board-Trials Methodology Research Network, College of Medicine, Nursing and Health Sciences, University of Galway, County Galway, Galway, Ireland
| | - Kirsty K O'Brien
- Health Technology Assessment Directorate, Health Information and Quality Authority, Cork, Ireland
| | - Marie Carrigan
- Health Technology Assessment Directorate, Health Information and Quality Authority, Cork, Ireland
| | - Susan Ahern
- Health Technology Assessment Directorate, Health Information and Quality Authority, Cork, Ireland
| | - Maeve McGarry
- Health Technology Assessment Directorate, Health Information and Quality Authority, Cork, Ireland
| | - Patricia Harrington
- Health Technology Assessment Directorate, Health Information and Quality Authority, Cork, Ireland
| | - Kieran A Walsh
- Health Technology Assessment Directorate, Health Information and Quality Authority, Cork, Ireland; School of Pharmacy, University College Cork, County Cork, Cork, Ireland
| | - Susan M Smith
- Discipline of Public Health & Primary Care, School of Medicine, Trinity College, Dublin, Ireland
| | - Máirín Ryan
- Health Technology Assessment Directorate, Health Information and Quality Authority, Cork, Ireland; Department of Pharmacology and Therapeutics, Trinity College, Dublin, Ireland
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Ma J, Yang Q, Ye X, Xu W, Chang Y, Chen R, Wang Y, Luo M, Lou Y, Yang X, Li D, Xu Y, He W, Cai M, Cao W, Ju G, Yin L, Wang J, Ren J, Ma Z, Zuo C, Ren S. Head-to-head comparison of prostate-specific membrane antigen PET and multiparametric MRI in the diagnosis of pretreatment patients with prostate cancer: a meta-analysis. Eur Radiol 2024; 34:4017-4037. [PMID: 37981590 DOI: 10.1007/s00330-023-10436-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/05/2023] [Accepted: 09/19/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVES To compare prostate-specific membrane antigen (PSMA) PET with multiparametric MRI (mpMRI) in the diagnosis of pretreatment prostate cancer (PCa). METHODS Pubmed, Embase, Medline, Web of Science, and Cochrane Library were searched for eligible studies published before June 22, 2022. We assessed risk of bias and applicability by using QUADAS-2 tool. Data synthesis was performed with Stata 17.0 software, using the "midas" and "meqrlogit" packages. RESULTS We included 29 articles focusing on primary cancer detection, 18 articles about primary staging, and two articles containing them both. For PSMA PET versus mpMRI in primary PCa detection, sensitivities and specificities in the per-patient analysis were 0.90 and 0.84 (p<0.0001), and 0.66 and 0.60 (p <0.0001), and in the per-lesion analysis they were 0.79 and 0.78 (p <0.0001), and 0.84 and 0.82 (p <0.0001). For the per-patient analysis of PSMA PET versus mpMRI in primary staging, sensitivities and specificities in extracapsular extension detection were 0.59 and 0.66 (p =0.005), and 0.79 and 0.76 (p =0.0074), and in seminal vesicle infiltration (SVI) detection they were 0.51 and 0.60 (p =0.0008), and 0.93 and 0.96 (p =0.0092). For PSMA PET versus mpMRI in lymph node metastasis (LNM) detection, sensitivities and specificities in the per-patient analysis were 0.68 and 0.46 (p <0.0001), and 0.91 and 0.90 (p =0.81), and in the per-lesion analysis they were 0.67 and 0.36 (p <0.0001), and 0.99 and 0.99 (p =0.18). CONCLUSION PSMA PET has higher diagnostic value than mpMRI in the detection of primary PCa. Regarding the primary staging, mpMRI has potential advantages in SVI detection, while PSMA PET has relative advantages in LNM detection. CLINICAL RELEVANCE STATEMENT The integration of prostate-specific membrane antigen (PSMA) PET into the diagnostic pathway may be helpful for improving the accuracy of prostate cancer detection. However, further studies are needed to address the cost implications and evaluate its utility in specific patient populations or clinical scenarios. Moreover, we recommend the combination of PSMA PET and mpMRI for cancer staging. KEY POINTS • Prostate-specific membrane antigen PET has higher sensitivity and specificity for primary tumor detection in prostate cancer compared to multiparametric MRI. • Prostate-specific membrane antigen PET also has significantly better sensitivity and specificity for lymph node metastases of prostate cancer compared to multiparametric MRI. • Multiparametric MRI has better accuracy for extracapsular extension and seminal vesicle infiltration compared to ate-specific membrane antigen PET.
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Affiliation(s)
- Jianglei Ma
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Qinqin Yang
- Department of Nuclear Medicine, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Xiaofei Ye
- Department of Health Statistics, Naval Medical University, Shanghai, 200433, China
| | - Weidong Xu
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Yifan Chang
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Rui Chen
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Ye Wang
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Mengting Luo
- College of Basic Medical Sciences, Naval Medical University, Shanghai, 200433, China
| | - Yihaoyun Lou
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Xuming Yang
- Department of Urology, Hengyang Central Hospital, Hengyang, 421001, Hu'nan, China
| | - Duocai Li
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Yusi Xu
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Wei He
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Minglei Cai
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Wanli Cao
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Guanqun Ju
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Lei Yin
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Junkai Wang
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Jizhong Ren
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Zifang Ma
- Department of Urology, Hengyang Central Hospital, Hengyang, 421001, Hu'nan, China.
| | - Changjing Zuo
- Department of Nuclear Medicine, Changhai Hospital, Naval Medical University, Shanghai, 200433, China.
| | - Shancheng Ren
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China.
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Ma KC, Mena E, Lindenberg L, Lay NS, Eclarinal P, Citrin DE, Pinto PA, Wood BJ, Dahut WL, Gulley JL, Madan RA, Choyke PL, Turkbey IB, Harmon SA. Deep learning-based whole-body PSMA PET/CT attenuation correction utilizing Pix-2-Pix GAN. Oncotarget 2024; 15:288-300. [PMID: 38712741 DOI: 10.18632/oncotarget.28583] [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: 05/08/2024] Open
Abstract
PURPOSE Sequential PET/CT studies oncology patients can undergo during their treatment follow-up course is limited by radiation dosage. We propose an artificial intelligence (AI) tool to produce attenuation-corrected PET (AC-PET) images from non-attenuation-corrected PET (NAC-PET) images to reduce need for low-dose CT scans. METHODS A deep learning algorithm based on 2D Pix-2-Pix generative adversarial network (GAN) architecture was developed from paired AC-PET and NAC-PET images. 18F-DCFPyL PSMA PET-CT studies from 302 prostate cancer patients, split into training, validation, and testing cohorts (n = 183, 60, 59, respectively). Models were trained with two normalization strategies: Standard Uptake Value (SUV)-based and SUV-Nyul-based. Scan-level performance was evaluated by normalized mean square error (NMSE), mean absolute error (MAE), structural similarity index (SSIM), and peak signal-to-noise ratio (PSNR). Lesion-level analysis was performed in regions-of-interest prospectively from nuclear medicine physicians. SUV metrics were evaluated using intraclass correlation coefficient (ICC), repeatability coefficient (RC), and linear mixed-effects modeling. RESULTS Median NMSE, MAE, SSIM, and PSNR were 13.26%, 3.59%, 0.891, and 26.82, respectively, in the independent test cohort. ICC for SUVmax and SUVmean were 0.88 and 0.89, which indicated a high correlation between original and AI-generated quantitative imaging markers. Lesion location, density (Hounsfield units), and lesion uptake were all shown to impact relative error in generated SUV metrics (all p < 0.05). CONCLUSION The Pix-2-Pix GAN model for generating AC-PET demonstrates SUV metrics that highly correlate with original images. AI-generated PET images show clinical potential for reducing the need for CT scans for attenuation correction while preserving quantitative markers and image quality.
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Affiliation(s)
- Kevin C Ma
- Artificial Intelligence Resource, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Esther Mena
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Liza Lindenberg
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Nathan S Lay
- Artificial Intelligence Resource, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Phillip Eclarinal
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Deborah E Citrin
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Peter A Pinto
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Bradford J Wood
- Center for Interventional Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - William L Dahut
- Genitourinary Malignancies Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - James L Gulley
- Center for Immuno-Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Ravi A Madan
- Genitourinary Malignancies Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Peter L Choyke
- Artificial Intelligence Resource, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Ismail Baris Turkbey
- Artificial Intelligence Resource, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Stephanie A Harmon
- Artificial Intelligence Resource, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
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Lawal IO, Ndlovu H, Kgatle M, Mokoala KMG, Sathekge MM. Prognostic Value of PSMA PET/CT in Prostate Cancer. Semin Nucl Med 2024; 54:46-59. [PMID: 37482489 DOI: 10.1053/j.semnuclmed.2023.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/11/2023] [Indexed: 07/25/2023]
Abstract
Prostate-specific membrane antigen (PSMA) is a transmembrane glycoprotein expressed in the majority of prostate cancer (PCa). PSMA has an enzymatic function that makes metabolic substrates such as folate available for utilization by PCa cells. Intracellular folate availability drives aggressive tumor phenotype. PSMA expression is, therefore, a marker of aggressive tumor biology. The large extracellular domain of PSMA is available for targeting by diagnostic and therapeutic radionuclides, making it a suitable cellular epitope for theranostics. PET imaging of radiolabeled PSMA ligands has several prognostic utilities. In the prebiopsy setting, intense PSMA avidity in a prostate lesion correlate well with clinically significant PCa (csPCa) on histology. When used for staging, PSMA PET imaging outperforms conventional imaging for the accurate staging of primary PCa, and findings on imaging predict post-treatment outcomes. The biggest contribution of PSMA PET imaging to PCa management is in the biochemical recurrence setting, where it has emerged as the most sensitive imaging modality for the localization of PCa recurrence by helping to guide salvage therapy. PSMA PET obtained for localizing the site of recurrence is prognostic, such that a higher lesion number predicts a less favorable outcome to salvage radiotherapy or surgical intervention. Systemic therapy is given to patients with advanced PCa with distant metastasis. PSMA PET is useful for predicting response to treatments with chemotherapy, first- and second-line androgen deprivation therapies, and PSMA-targeted radioligand therapy. Artificial intelligence using machine learning algorithms allows for the mining of information from clinical images not visible to the human eyes. Artificial intelligence applied to PSMA PET images, therefore, holds great promise for prognostication in PCa management.
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Affiliation(s)
- Ismaheel O Lawal
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA; Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa
| | - Honest Ndlovu
- Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa; Nuclear Medicine Research Infrastructure (NuMeRI), Steve Biko Academic Hospital, Pretoria, South Africa
| | - Mankgopo Kgatle
- Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa; Nuclear Medicine Research Infrastructure (NuMeRI), Steve Biko Academic Hospital, Pretoria, South Africa
| | - Kgomotso M G Mokoala
- Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa; Nuclear Medicine Research Infrastructure (NuMeRI), Steve Biko Academic Hospital, Pretoria, South Africa
| | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa; Nuclear Medicine Research Infrastructure (NuMeRI), Steve Biko Academic Hospital, Pretoria, South Africa.
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Olkowski C, Fernandes B, Griffiths GL, Lin F, Choyke PL. Preclinical Imaging of Prostate Cancer. Semin Nucl Med 2023; 53:644-662. [PMID: 36882335 PMCID: PMC10440231 DOI: 10.1053/j.semnuclmed.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/01/2023] [Indexed: 03/07/2023]
Abstract
Prostate cancer remains a major cause of mortality and morbidity, affecting millions of men, with a large percentage expected to develop the disease as they reach advanced ages. Treatment and management advances have been dramatic over the past 50 years or so, and one aspect of these improvements is reflected in the multiple advances in diagnostic imaging techniques. Much attention has been focused on molecular imaging techniques that offer high sensitivity and specificity and can now more accurately assess disease status and detect recurrence earlier. During development of molecular imaging probes, single-photon emission computed tomography (SPECT) and positron emission tomography (PET) must be evaluated in preclinical models of the disease. If such agents are to be translated to the clinic, where patients undergoing these imaging modalities are injected with a molecular imaging probe, these agents must first be approved by the FDA and other regulatory agencies prior to their adoption in clinical practice. Scientists have worked assiduously to develop preclinical models of prostate cancer that are relevant to the human disease to enable testing of these probes and related targeted drugs. Challenges in developing reproducible and robust models of human disease in animals are beset with practical issues such as the lack of natural occurrence of prostate cancer in mature male animals, the difficulty of initiating disease in immune-competent animals and the sheer size differences between humans and conveniently smaller animals such as rodents. Thus, compromises in what is ideal and what can be achieved have had to be made. The workhorse of preclinical animal models has been, and remains, the investigation of human xenograft tumor models in athymic immunocompromised mice. Later models have used other immunocompromised models as they have been found and developed, including the use of directly derived patient tumor tissues, completely immunocompromised mice, orthotopic methods for inducing prostate cancer within the mouse prostate itself and metastatic models of advanced disease. These models have been developed in close parallel with advances in imaging agent chemistries, radionuclide developments, computer electronics advances, radiometric dosimetry, biotechnologies, organoid technologies, advances in in vitro diagnostics, and overall deeper understandings of disease initiation, development, immunology, and genetics. The combination of molecular models of prostatic disease with radiometric-based studies in small animals will always remain spatially limited due to the inherent resolution sensitivity limits of PET and SPECT decay processes, fundamentally set at around a 0.5 cm resolution limit. Nevertheless, it is central to researcher's efforts and to successful clinical translation that the best animal models are adopted, accepted, and scientifically verified as part of this truly interdisciplinary approach to addressing this important disease.
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Affiliation(s)
- Colleen Olkowski
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute, Bethesda MD
| | - Bruna Fernandes
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute, Bethesda MD
| | - Gary L Griffiths
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Frank Lin
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute, Bethesda MD
| | - Peter L Choyke
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute, Bethesda MD.
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Wang YF, Lo CY, Chen LY, Chang CW, Huang YT, Huang YY, Huang YH. Comparing the Detection Performance Between Multiparametric Magnetic Resonance Imaging and Prostate-Specific Membrane Antigen PET/CT in Patients With Localized Prostate Cancer: A Systematic Review and Meta-analysis. Clin Nucl Med 2023; 48:e321-e331. [PMID: 37145456 DOI: 10.1097/rlu.0000000000004646] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE Multiparametric MRI (mpMRI) has been promoted as an auxiliary diagnostic tool for prostate biopsy. However, prostate-specific membrane antigen (PSMA) including 68 Ga-PSMA-11, 18 F-DCFPyL, and 18 F-PSMA-1007 applied PET/CT imaging was an emerging diagnostic tool in prostate cancer patients for staging or posttreatment follow-up, even early detecting. Many studies have used PSMA PET for comparison with mpMRI to test the diagnostic ability for early prostate cancer. Unfortunately, these studies have shown conflicting results. This meta-analysis aimed to compare the differences in diagnostic performance between PSMA PET and mpMRI for detecting and T staging localized prostatic tumors. METHODS This meta-analysis involved a systematic literature search of PubMed/MEDLINE and Cochrane Library databases. The pooling sensitivity and specificity of PSMA and mpMRI verified by pathological analysis were calculated and used to compare the differences between the 2 imaging tools. RESULTS Overall, 39 studies were included (3630 patients in total) from 2016 to 2022 in the current meta-analysis and found that the pooling sensitivity values for localized prostatic tumors and T staging T3a and T3b of PSMA PET were 0.84 (95% confidence interval [CI], 0.83-0.86), 0.61 (95% CI, 0.39-0.79), and 0.62 (95% CI, 0.46-0.76), respectively, whereas those of mpMRI were found to be 0.84 (95% 0.78-0.89), 0.67 (95% CI, 0.52-0.80), and 0.60 (95% CI, 0.45-0.73), respectively, without significant differences ( P > 0.05). However, in a subgroup analysis of radiotracer, the pooling sensitivity of 18 F-DCFPyL PET was higher than mpMRI (relative risk, 1.10; 95% CI, 1.03-1.17; P < 0.01). CONCLUSIONS This meta-analysis found that whereas 18 F-DCFPyL PET was superior to mpMRI at detecting localized prostatic tumors, the detection performance of PSMA PET for localized prostatic tumors and T staging was comparable to that of mpMRI.
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A Systematic Review of the Variability in Performing and Reporting Intraprostatic Prostate-specific Membrane Antigen Positron Emission Tomography in Primary Staging Studies. EUR UROL SUPPL 2023; 50:91-105. [PMID: 37101769 PMCID: PMC10123424 DOI: 10.1016/j.euros.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 03/06/2023] Open
Abstract
Context Prostate cancer (PCa) remains one of the leading causes of cancer-related deaths in men worldwide. Men at risk are typically offered multiparametric magnetic resonance imaging and, if suspicious, a targeted biopsy. However, false-negative rates of magnetic resonance imaging are consistently 18%; therefore, there is growing interest in improving the diagnostic performance of imaging through novel technologies. Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) is being utilised for PCa staging and, more recently, for intraprostatic tumour localisation. However, significant variability has been observed in how PSMA PET is performed and reported. Objective In this review, we aim to evaluate how pervasive this variability is in trials investigating the performance of PSMA PET in primary PCa workup. Evidence acquisition Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we performed an optimal search in five different databases. After removing duplicates, 65 studies were included in our review. Evidence synthesis Studies dated back as early as 2016, with numerous different source countries. There was variation in the reference standard for PSMA PET, with some using biopsy specimens or surgical specimens, and in some cases, a combination of the two. Similar inconsistencies were noted when studies selected histological definitions of clinically significant PCa, while some omitted their definition altogether. The most significant variations in performing PSMA PET were the radiotracer type, dose, acquisition time after injection, and the PET camera being utilised. Substantial variation in the reporting of PSMA PET was noted, with no consistency in defining what constitutes a positive intraprostatic lesion. Across 65 studies, four different definitions were used. Conclusions This systematic review has highlighted considerable variation in obtaining and performing a PSMA PET study in the context of primary PCa diagnosis. Given the discrepancy in how PSMA PET was performed and reported, it questions the homogony of studies from centre to centre. Standardisation of PSMA PET is required for this to become a consistently useful and reproducible modality in the diagnosis of PCa. Patient summary Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) is being utilised for staging and localisation of prostate cancer (PCa); however, there is significant variability in performing and reporting PSMA PET. Standardisation of PSMA PET is required for results to be consistently useful and reproducible for the diagnosis of PCa.
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Incidental Findings of Coexisting Metastatic Pancreatic Cancer in Patients With Prostate Cancer on 18 F-Prostate-Specific Membrane Antigen PET/CT. Clin Nucl Med 2022; 47:1103-1104. [PMID: 35835124 DOI: 10.1097/rlu.0000000000004338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT A 79-year-old man with rising prostate-specific antigen of 3.2 ng/mL and diagnosis of metastatic castration-resistant prostate cancer received abiraterone and prednisone for treatment regarding prostate-specific membrane antigen (PSMA)-avid bone lesions on PET/CT. Four months later, a follow-up 18 F-DCFPyL PET/CT demonstrated new and increased multifocal PSMA-avid osseous and liver lesions, whereas prostate-specific antigen was stabled at 3.1 ng/mL. Biopsy of liver lesion showed metastasis from a primary pancreatic acinar cell carcinoma. Retrospectively, PSMA-avid pancreatic body lesion was identified on both PSMA PET/CT scans. This case illustrated that any above background PSMA uptake in the pancreas warrants suspicion for malignancy.
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Tran V, Hong A, Sutherland T, Taubman K, Lee SF, Lenaghan D, Sethi K, Corcoran NM, Lawrentschuk N, Woo H, Tarlinton L, Bolton D, Spelman T, Thomas L, Booth R, Hegarty J, Perry E, Wong LM. PEDAL protocol: a prospective single-arm paired comparison of multiparametric MRI and 18F-DCPFyl PSMA PET/CT to diagnose prostate cancer. BMJ Open 2022; 12:e061815. [PMID: 36123093 PMCID: PMC9486365 DOI: 10.1136/bmjopen-2022-061815] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Prostate-specific membrane antigen positron emission tomography (PSMA-PET) has emerged as valuable imaging to assessing metastatic disease in prostate malignancy. However, there has been limited studies exploring the utility PSMA-PET as primary imaging assessing for index lesions prior to biopsy. The primary objective of this study is to compare the diagnostic accuracy of 18-fluorine PSMA (18F DCFPyL PSMA) PET scans to multiparametric MRI (mpMRI) to detect primary prostate cancer at prostate biopsy. METHODS AND ANALYSIS The PEDAL trial is a multicentre, prospective, single-arm, paired comparison, non-randomised phase III trial in subjects considered for diagnostic prostate biopsy. Subjects who are eligible for a diagnostic mpMRI prostate will undergo additional same-day 18 F DCFPyl PSMA PET/CT of the chest, abdomen and pelvis. Software coregistration of the mpMRI and PSMA-PET/CT images will be performed. The reporting of the mpMRI prostate, PSMA-PET/CT and PSMA PET/MRI coregistration will be performed blinded. The diagnostic accuracy of PSMA PET/CT alone, and in combination with mpMRI, to detect prostate cancer will be assessed. Histopathology at prostate biopsy will be used as the reference standard. Sample size calculations estimate that 240 subjects will need to be recruited to demonstrate 20% superiority of PSMA-PET/CT. The sensitivity, specificity, positive predictive value and negative predictive value of the combination of mpMRI prostate and PSMA PET/CT compared with targeted and systematic prostate biopsy will be evaluated. It is hypothesised that PSMA PET/CT combined with mpMRI prostate will have improved diagnostic accuracy compared with mpMRI prostate alone for detection of prostate cancer in biopsy-naïve men, resulting in a significant impact on patient management. ETHICS AND DISSEMINATION This study was approved by the independent Human Research Ethics Committee. Results will be published in peer-reviewed medical journals with eligible investigators will significantly contribute. TRIAL REGISTRATION NUMBER ACTRN12620000261910.
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Affiliation(s)
- Vy Tran
- Department of Urology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Anne Hong
- Department of Urology, Austin Health, Heidelberg, Victoria, Australia
| | - Tom Sutherland
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Medical Imaging, St Vincent's Hospital Melbourne Pty Ltd, Melbourne, Victoria, Australia
| | - Kim Taubman
- Department of Nuclear Medicine, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
| | - Su-Faye Lee
- Department of Nuclear Medicine, St Vincent's Hospital Melbourne Pty Ltd, Melbourne, Victoria, Australia
| | - Daniel Lenaghan
- Department of Urology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
| | - Kapil Sethi
- Department of Urology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Niall M Corcoran
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Urology, The Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
| | - Nathan Lawrentschuk
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Urology, The Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
| | - H Woo
- Department of Urology, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
- Department of Surgery, The University of Sydney, Sydney, New South Wales, Australia
| | - Lisa Tarlinton
- San Radiology and Nuclear Medicine, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
| | - Damien Bolton
- Department of Urology, Austin Health, Heidelberg, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Tim Spelman
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lauren Thomas
- Department of Nuclear Medicine, St Vincent's Hospital Melbourne Pty Ltd, Melbourne, Victoria, Australia
| | - Russell Booth
- Department of Nuclear Medicine, St Vincent's Hospital Melbourne Pty Ltd, Melbourne, Victoria, Australia
| | - Justin Hegarty
- Pacific Radiology Christchurch, Christchurch, Canterbury, New Zealand
| | - Elisa Perry
- Pacific Radiology Christchurch, Christchurch, Canterbury, New Zealand
| | - Lih-Ming Wong
- Department of Urology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
- Department of Urology, Austin Health, Heidelberg, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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10
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Huang YT, Tseng NC, Chen YK, Huang KH, Lin HY, Huang YY, Hwang TIS, Ou YC. The Detection Performance of 18 F-Prostate-Specific Membrane Antigen-1007 PET/CT in Primary Prostate Cancer : A Systemic Review and Meta-analysis. Clin Nucl Med 2022; 47:755-762. [PMID: 35452013 DOI: 10.1097/rlu.0000000000004228] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Multiple tools are now available to determine the requirement for a biopsy to diagnose prostate cancer, and PET/CT with radiolabeled prostate-specific membrane antigen (PSMA)-targeting radiotracers has been recommended for detecting primary prostate cancer. Particularly, the radiotracer 18 F-PSMA-1007 was found to be more favorable for primary tumors compared with other PSMA-targeting radiotracers because of its low clearance via the urinary tract and better image resolution. Thus, we performed a systematic review and meta-analysis to more accurately evaluate the detection performance of 18 F-PSMA-1007 PET/CT in primary prostate cancer patients. METHODS An update on the databases of PubMed/MEDLINE, EMBASE, and Cochrane Library for comprehensive literature search was performed on September 30, 2021. The pooling detection rate was calculated on a per-patient basis. The pooling median of the SUV max was analyzed from the included studies. Furthermore, the positive predictive value of 18 F-PSMA-1007 PET/CT with pathologic lesions was analyzed using the criterion standard. RESULTS Twelve studies (540 patients total) were included in the meta-analysis. The overall pooling detection rate of 18 F-PSMA-1007 per patient was 94%, and the pooling median of SUV max located at the intraprostate tumor was 16 (range, 3.7-77.7). The positive predictive value of 18 F-PSMA-1007 per lesion with histopathological validation was 0.90, detecting regional lymph node metastasis was 0.94, and detecting localized prostatic tumors was 0.84. CONCLUSIONS In the current meta-analysis, we revealed the excellent performance of 18 F-PSMA-1007 to detect localized prostatic tumor lesions and regional lymph node metastasis. Moreover, the uptake of localized tumors in primary prostate cancer was nearly liver uptake and may be considered a suspicious malignancy if it was equal to or greater than the liver uptake.
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11
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Fukushima H, Turkbey B, Pinto PA, Furusawa A, Choyke PL, Kobayashi H. Near-Infrared Photoimmunotherapy (NIR-PIT) in Urologic Cancers. Cancers (Basel) 2022; 14:2996. [PMID: 35740662 PMCID: PMC9221010 DOI: 10.3390/cancers14122996] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/12/2022] [Accepted: 06/14/2022] [Indexed: 11/16/2022] Open
Abstract
Near-infrared photoimmunotherapy (NIR-PIT) is a novel molecularly-targeted therapy that selectively kills cancer cells by systemically injecting an antibody-photoabsorber conjugate (APC) that binds to cancer cells, followed by the application of NIR light that drives photochemical transformations of the APC. APCs are synthesized by selecting a monoclonal antibody that binds to a receptor on a cancer cell and conjugating it to IRDye700DX silica-phthalocyanine dye. Approximately 24 h after APC administration, NIR light is delivered to the tumor, resulting in nearly-immediate necrotic cell death of cancer cells while causing no harm to normal tissues. In addition, NIR-PIT induces a strong immunologic effect, activating anti-cancer immunity that can be further boosted when combined with either immune checkpoint inhibitors or immune suppressive cell-targeted (e.g., regulatory T cells) NIR-PIT. Currently, a global phase III study of NIR-PIT in recurrent head and neck squamous cell carcinoma is ongoing. The first APC and NIR laser systems were approved for clinical use in September 2020 in Japan. In the near future, the clinical applications of NIR-PIT will expand to other cancers, including urologic cancers. In this review, we provide an overview of NIR-PIT and its possible applications in urologic cancers.
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Affiliation(s)
- Hiroshi Fukushima
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute (NIH), Bethesda, MD 20892, USA; (H.F.); (B.T.); (A.F.); (P.L.C.)
| | - Baris Turkbey
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute (NIH), Bethesda, MD 20892, USA; (H.F.); (B.T.); (A.F.); (P.L.C.)
| | - Peter A. Pinto
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute (NIH), Bethesda, MD 20892, USA;
| | - Aki Furusawa
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute (NIH), Bethesda, MD 20892, USA; (H.F.); (B.T.); (A.F.); (P.L.C.)
| | - Peter L. Choyke
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute (NIH), Bethesda, MD 20892, USA; (H.F.); (B.T.); (A.F.); (P.L.C.)
| | - Hisataka Kobayashi
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute (NIH), Bethesda, MD 20892, USA; (H.F.); (B.T.); (A.F.); (P.L.C.)
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12
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Lu M, Lindenberg L, Mena E, Turkbey B, Seidel J, Ton A, McKinney Y, Eclarinal P, Merino M, Pinto P, Choyke P, Adler S. A Pilot Study of Dynamic 18F-DCFPyL PET/CT Imaging of Prostate Adenocarcinoma in High-Risk Primary Prostate Cancer Patients. Mol Imaging Biol 2022; 24:444-452. [PMID: 34724140 PMCID: PMC10572101 DOI: 10.1007/s11307-021-01670-5] [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: 08/31/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The primary aim of this study was to investigate the pharmacokinetics of 18F-DCFPyL, an 18F-labeled PSMA-based ligand, and to explore the utility of early time point positron emission tomography (PET) imaging extracted from PET data to distinguish malignant primary prostate from benign prostate tissue. PROCEDURES Ten consecutive patients with biopsy-proven high-risk prostate cancer underwent a dynamic 18F-DCFPyL PET/CT scan of the pelvis for the first 45 min post-injection (p.i.) followed by a static PET/CT at 2 h p.i. 18F-DCFPyL uptake values and kinetics were compared between benign prostate tissue and prostate cancer, including quantitative pharmacokinetic PET parameters extracted from 18F-DCFPyL time activity curves generated from dynamic data using a two-tissue compartment model and Patlak plots. RESULTS 18F-DCFPyL uptake values were significantly higher in primary prostate tumors than those in benign prostatic hyperplasia (BPH) and normal prostate tissue at 5 min, 30 min, and 120 min p.i. (P = 0.0002), when examining both SUVmax and SUVmean values. The two-tissue compartment model found an overall influx value (Ki) of 0.063 in primary prostate cancer, demonstrating a Ki over 15-fold higher in malignant prostate tissue compared with BPH (Ki = 0.004) and normal prostate tissue (Ki = 0.005) (P = 0.0001). CONCLUSION High-risk primary prostate cancer is readily identified on dynamic and static, delayed, 18F-DCFPyL PET images. The tumor-to-background ratio increases over time, with optimal 18F-DCFPyL PET/CT imaging at 120 min p.i. for evaluation of prostate cancer, but not necessarily ideal for clinical application. Primary prostate cancer demonstrates different uptake kinetics in comparison to BPH and normal prostate tissue. The 15-fold difference in Ki between prostate cancer and non-cancer (BPH and normal) tissues translates to an ability to distinguish prostate cancer from normal tissue at time points as early as 5 to 10 min p.i.
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Affiliation(s)
- Michelle Lu
- Molecular Imaging Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Liza Lindenberg
- Molecular Imaging Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Esther Mena
- Molecular Imaging Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Baris Turkbey
- Molecular Imaging Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Jurgen Seidel
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Anita Ton
- Molecular Imaging Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Yolanda McKinney
- Molecular Imaging Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Philip Eclarinal
- Molecular Imaging Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Maria Merino
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, USA
| | - Peter Pinto
- Urologic Oncology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Peter Choyke
- Molecular Imaging Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Stephen Adler
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA.
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13
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Unusual Metastatic Prostate Cancer in Subcarinal Lymph Node and Peritoneal Nodule Found on 18F-PSMA PET/CT With Rising PSA of 0.4 ng/mL. Clin Nucl Med 2022; 47:989-990. [PMID: 35619200 DOI: 10.1097/rlu.0000000000004294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT A 79-year-old man with metastatic prostate cancer underwent radical prostatectomy and bilateral lymph node dissection and received multiple lines of systematic treatment for his biopsy-proven peritoneal carcinomatosis. During the disease course, his prostate-specific antigen rose from 0.1 ng/mL to 0.4 ng/mL in 4 months, and testosterone level was <3 ng/dL. Workup 18F-DCFPyL PET/CT showed unusual prostate-specific membrane antigen-avid, 1.1-cm subcarinal lymph node and a 0.8-cm peritoneal nodule, which were not hypermetabolic on an 18F-FDG PET/CT 6 days later. This case illustrated the sensitivity for 18F-DCFPyL PET/CT in detecting metastatic castration-resistant prostate cancer.
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14
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Voter AF, Werner RA, Pienta KJ, Gorin MA, Pomper MG, Solnes LB, Rowe SP. Piflufolastat F-18 ( 18F-DCFPyL) for PSMA PET imaging in prostate cancer. Expert Rev Anticancer Ther 2022; 22:681-694. [DOI: 10.1080/14737140.2022.2081155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Andrew F. Voter
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Transitional Year Residency Program, Aurora St. Luke’s Medical Center, Advocate Aurora Health, Milwaukee, WI, USA
| | - Rudolf A. Werner
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Kenneth J. Pienta
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael A. Gorin
- Urology Associates and UPMC Western Maryland, Cumberland, MD, USA
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Martin G. Pomper
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lilja B. Solnes
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven P. Rowe
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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15
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Liu W, Loblaw A, Laidley D, Fakir H, Mendez L, Davidson M, Kassam Z, Lee TY, Ward A, Thiessen J, Bayani J, Conyngham J, Bailey L, Andrews JD, Bauman G. Imaging Biomarkers in Prostate Stereotactic Body Radiotherapy: A Review and Clinical Trial Protocol. Front Oncol 2022; 12:863848. [PMID: 35494042 PMCID: PMC9043802 DOI: 10.3389/fonc.2022.863848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Advances in imaging have changed prostate radiotherapy through improved biochemical control from focal boost and improved detection of recurrence. These advances are reviewed in the context of prostate stereotactic body radiation therapy (SBRT) and the ARGOS/CLIMBER trial protocol. ARGOS/CLIMBER will evaluate 1) the safety and feasibility of SBRT with focal boost guided by multiparametric MRI (mpMRI) and 18F-PSMA-1007 PET and 2) imaging and laboratory biomarkers for response to SBRT. To date, response to prostate SBRT is most commonly evaluated using the Phoenix Criteria for biochemical failure. The drawbacks of this approach include lack of lesion identification, a high false-positive rate, and delay in identifying treatment failure. Patients in ARGOS/CLIMBER will receive dynamic 18F-PSMA-1007 PET and mpMRI prior to SBRT for treatment planning and at 6 and 24 months after SBRT to assess response. Imaging findings will be correlated with prostate-specific antigen (PSA) and biopsy results, with the goal of early, non-invasive, and accurate identification of treatment failure.
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Affiliation(s)
- Wei Liu
- Department of Oncology, Division of Radiation Oncology, London Health Sciences Centre and Western University, London, ON, Canada
| | - Andrew Loblaw
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre and Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - David Laidley
- Division of Nuclear Medicine, St. Joseph's Health Centre and Western University, London, ON, Canada
| | - Hatim Fakir
- Department of Oncology and Department of Medical Biophysics, London Health Sciences Centre and Western University, London, ON, Canada
| | - Lucas Mendez
- Department of Oncology, Division of Radiation Oncology, London Health Sciences Centre and Western University, London, ON, Canada
| | - Melanie Davidson
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre and Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Zahra Kassam
- Department of Medical Imaging, St. Joseph's Health Care and Western University, London, ON, Canada
| | - Ting-Yim Lee
- Department of Medical Biophysics, Western University and Lawson Health Research Institute, London, ON, Canada
| | - Aaron Ward
- Department of Medical Biophysics, Western University and Lawson Health Research Institute, London, ON, Canada
| | - Jonathan Thiessen
- Department of Medical Biophysics, Western University and Lawson Health Research Institute, London, ON, Canada
| | - Jane Bayani
- Ontario Institute for Cancer Research and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | | | - Laura Bailey
- Clinical Research Unit, London Regional Cancer Program, London, ON, Canada
| | - Joseph D Andrews
- Clinical Research Unit, London Regional Cancer Program, London, ON, Canada
| | - Glenn Bauman
- Department of Oncology, Division of Radiation Oncology, London Health Sciences Centre and Western University, London, ON, Canada
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16
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Rothberg MB, Enders JJ, Kozel Z, Gopal N, Turkbey B, Pinto PA. The role of novel imaging in prostate cancer focal therapy: treatment and follow-up. Curr Opin Urol 2022; 32:231-238. [PMID: 35275101 DOI: 10.1097/mou.0000000000000986] [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: 11/26/2022]
Abstract
PURPOSE OF REVIEW Multiparametric magnetic resonance imaging (mpMRI) has fundamentally changed how intraprostatic lesions are visualized, serving as a highly sensitive means for detecting clinically significant prostate cancer (csPCa) via image-targeted biopsy. However, limitations associated with mpMRI have led to the development of new imaging technologies with the goal of better characterizing intraprostatic disease burden to more accurately guide treatment planning and surveillance for prostate cancer focal therapy. Herein, we review several novel imaging modalities with an emphasis on clinical data reported within the past two years. RECENT FINDINGS 7T MRI, artificial intelligence applied to mpMRI, positron emission tomography combined with either computerized tomography or MRI, contrast-enhanced ultrasound, and micro-ultrasound are novel imaging modalities with the potential to further improve intraprostatic lesion localization for applications in focal therapy for prostate cancer. Many of these technologies have demonstrated equivalent or favorable diagnostic accuracy compared to contemporary mpMRI for identifying csPCa and some have even shown improved capabilities to define lesion borders, to provide volumetric estimates of lesions, and to assess the adequacy of focal ablation of planned treatment zones. SUMMARY Novel imaging modalities with capabilities to better characterize intraprostatic lesions have the potential to improve accuracy in treatment planning, real-time assessment of the ablation zone, and posttreatment surveillance; however, many of these technologies require further validation to determine their clinical utility.
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Affiliation(s)
- Michael B Rothberg
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute
| | - Jacob J Enders
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute
| | - Zachary Kozel
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute
| | - Nikhil Gopal
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute
| | - Baris Turkbey
- Molecular Imaging Branch, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter A Pinto
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute
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17
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Yadav D, Hwang H, Qiao W, Upadhyay R, Chapin BF, Tang C, Aparicio A, Lopez-Olivo MA, Kang SK, Macapinlac HA, Bathala TK, Surasi DS. 18F-Fluciclovine versus PSMA PET Imaging in Primary Tumor Detection during Initial Staging of High-Risk Prostate Cancer: A Systematic Review and Meta-Analysis. Radiol Imaging Cancer 2022; 4:e210091. [PMID: 35212559 PMCID: PMC8965534 DOI: 10.1148/rycan.210091] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/28/2021] [Accepted: 01/20/2022] [Indexed: 06/14/2023]
Abstract
Purpose Fluorine 18 (18F)-fluciclovine and prostate-specific membrane antigen (PSMA) tracers are commonly used for localizing biochemical recurrence of prostate cancer, but their accuracy in primary tumor detection in the initial staging of high-risk prostate cancer has not been established. Materials and Methods A systematic review was performed of the electronic databases for original studies published between 2012 and 2020. Included studies were those in which 18F-fluciclovine or PSMA PET was used for initial staging of patients with high-risk prostate cancer. The diagnostic performance data were collected for primary tumor with histopathologic results as reference standard. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used for quality appraisal. A random-effects model was used to summarize the effect sizes and to evaluate the difference between two groups. Results Overall, 28 studies met the eligibility criteria, and 17 were included in the meta-analysis (18F-fluciclovine = 4, PSMA = 13). Of these 17 studies, 12 (70%) were judged to have high risk of bias in one of the evaluated domains, and nine studies were deemed to have applicability concerns. The pooled sensitivity, specificity, and diagnostic odds ratio for 18F-fluciclovine versus PSMA were 85% (95% CI: 73%, 92%) versus 84% (95% CI: 77%, 89%) (P = .78), 77% (95% CI: 60%, 88%) versus 83% (95% CI: 76%, 89%) (P = .40), and 18.88 (95% CI: 5.01, 71.20) versus 29.37 (95% CI: 13.35, 64.60) (P = .57), respectively, with no significant difference in diagnostic test accuracy. Conclusion 18F-fluciclovine and PSMA PET demonstrated no statistically significant difference in diagnostic accuracy in primary tumor detection during initial staging of high-risk prostate cancer. Keywords: PET, Prostate, Molecular Imaging-Cancer, Staging Supplemental material is available for this article. © RSNA, 2022.
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Affiliation(s)
- Divya Yadav
- From the Departments of Radiation Oncology (D.Y., R.U., C.T.),
Biostatistics (H.H., W.Q.), Urology (B.F.C.), Genitourinary Medical Oncology
(A.A.), Health Services Research (M.A.L.O.), Nuclear Medicine (H.A.M., D.S.S.),
and Abdominal Imaging (T.K.B.), The University of Texas MD Anderson Cancer
Center, 1515 Holcombe Blvd, Unit 483, Houston, TX 77030; and Department of
Radiology, NYU Langone Health, New York, NY (S.K.K.)
| | - Hyunsoo Hwang
- From the Departments of Radiation Oncology (D.Y., R.U., C.T.),
Biostatistics (H.H., W.Q.), Urology (B.F.C.), Genitourinary Medical Oncology
(A.A.), Health Services Research (M.A.L.O.), Nuclear Medicine (H.A.M., D.S.S.),
and Abdominal Imaging (T.K.B.), The University of Texas MD Anderson Cancer
Center, 1515 Holcombe Blvd, Unit 483, Houston, TX 77030; and Department of
Radiology, NYU Langone Health, New York, NY (S.K.K.)
| | - Wei Qiao
- From the Departments of Radiation Oncology (D.Y., R.U., C.T.),
Biostatistics (H.H., W.Q.), Urology (B.F.C.), Genitourinary Medical Oncology
(A.A.), Health Services Research (M.A.L.O.), Nuclear Medicine (H.A.M., D.S.S.),
and Abdominal Imaging (T.K.B.), The University of Texas MD Anderson Cancer
Center, 1515 Holcombe Blvd, Unit 483, Houston, TX 77030; and Department of
Radiology, NYU Langone Health, New York, NY (S.K.K.)
| | - Rituraj Upadhyay
- From the Departments of Radiation Oncology (D.Y., R.U., C.T.),
Biostatistics (H.H., W.Q.), Urology (B.F.C.), Genitourinary Medical Oncology
(A.A.), Health Services Research (M.A.L.O.), Nuclear Medicine (H.A.M., D.S.S.),
and Abdominal Imaging (T.K.B.), The University of Texas MD Anderson Cancer
Center, 1515 Holcombe Blvd, Unit 483, Houston, TX 77030; and Department of
Radiology, NYU Langone Health, New York, NY (S.K.K.)
| | - Brian F. Chapin
- From the Departments of Radiation Oncology (D.Y., R.U., C.T.),
Biostatistics (H.H., W.Q.), Urology (B.F.C.), Genitourinary Medical Oncology
(A.A.), Health Services Research (M.A.L.O.), Nuclear Medicine (H.A.M., D.S.S.),
and Abdominal Imaging (T.K.B.), The University of Texas MD Anderson Cancer
Center, 1515 Holcombe Blvd, Unit 483, Houston, TX 77030; and Department of
Radiology, NYU Langone Health, New York, NY (S.K.K.)
| | - Chad Tang
- From the Departments of Radiation Oncology (D.Y., R.U., C.T.),
Biostatistics (H.H., W.Q.), Urology (B.F.C.), Genitourinary Medical Oncology
(A.A.), Health Services Research (M.A.L.O.), Nuclear Medicine (H.A.M., D.S.S.),
and Abdominal Imaging (T.K.B.), The University of Texas MD Anderson Cancer
Center, 1515 Holcombe Blvd, Unit 483, Houston, TX 77030; and Department of
Radiology, NYU Langone Health, New York, NY (S.K.K.)
| | - Ana Aparicio
- From the Departments of Radiation Oncology (D.Y., R.U., C.T.),
Biostatistics (H.H., W.Q.), Urology (B.F.C.), Genitourinary Medical Oncology
(A.A.), Health Services Research (M.A.L.O.), Nuclear Medicine (H.A.M., D.S.S.),
and Abdominal Imaging (T.K.B.), The University of Texas MD Anderson Cancer
Center, 1515 Holcombe Blvd, Unit 483, Houston, TX 77030; and Department of
Radiology, NYU Langone Health, New York, NY (S.K.K.)
| | - Maria A. Lopez-Olivo
- From the Departments of Radiation Oncology (D.Y., R.U., C.T.),
Biostatistics (H.H., W.Q.), Urology (B.F.C.), Genitourinary Medical Oncology
(A.A.), Health Services Research (M.A.L.O.), Nuclear Medicine (H.A.M., D.S.S.),
and Abdominal Imaging (T.K.B.), The University of Texas MD Anderson Cancer
Center, 1515 Holcombe Blvd, Unit 483, Houston, TX 77030; and Department of
Radiology, NYU Langone Health, New York, NY (S.K.K.)
| | - Stella K. Kang
- From the Departments of Radiation Oncology (D.Y., R.U., C.T.),
Biostatistics (H.H., W.Q.), Urology (B.F.C.), Genitourinary Medical Oncology
(A.A.), Health Services Research (M.A.L.O.), Nuclear Medicine (H.A.M., D.S.S.),
and Abdominal Imaging (T.K.B.), The University of Texas MD Anderson Cancer
Center, 1515 Holcombe Blvd, Unit 483, Houston, TX 77030; and Department of
Radiology, NYU Langone Health, New York, NY (S.K.K.)
| | - Homer A. Macapinlac
- From the Departments of Radiation Oncology (D.Y., R.U., C.T.),
Biostatistics (H.H., W.Q.), Urology (B.F.C.), Genitourinary Medical Oncology
(A.A.), Health Services Research (M.A.L.O.), Nuclear Medicine (H.A.M., D.S.S.),
and Abdominal Imaging (T.K.B.), The University of Texas MD Anderson Cancer
Center, 1515 Holcombe Blvd, Unit 483, Houston, TX 77030; and Department of
Radiology, NYU Langone Health, New York, NY (S.K.K.)
| | - Tharakeswara K. Bathala
- From the Departments of Radiation Oncology (D.Y., R.U., C.T.),
Biostatistics (H.H., W.Q.), Urology (B.F.C.), Genitourinary Medical Oncology
(A.A.), Health Services Research (M.A.L.O.), Nuclear Medicine (H.A.M., D.S.S.),
and Abdominal Imaging (T.K.B.), The University of Texas MD Anderson Cancer
Center, 1515 Holcombe Blvd, Unit 483, Houston, TX 77030; and Department of
Radiology, NYU Langone Health, New York, NY (S.K.K.)
| | - Devaki Shilpa Surasi
- From the Departments of Radiation Oncology (D.Y., R.U., C.T.),
Biostatistics (H.H., W.Q.), Urology (B.F.C.), Genitourinary Medical Oncology
(A.A.), Health Services Research (M.A.L.O.), Nuclear Medicine (H.A.M., D.S.S.),
and Abdominal Imaging (T.K.B.), The University of Texas MD Anderson Cancer
Center, 1515 Holcombe Blvd, Unit 483, Houston, TX 77030; and Department of
Radiology, NYU Langone Health, New York, NY (S.K.K.)
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Value of Targeted Biopsies and Combined PSMA PET/CT and mp-MRI Imaging in Locally Recurrent Prostate Cancer after Primary Radiotherapy. Cancers (Basel) 2022; 14:cancers14030781. [PMID: 35159048 PMCID: PMC8834189 DOI: 10.3390/cancers14030781] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary After primary radiotherapy for prostate cancer, patients may develop an isolated local recurrence. The diagnostic workup of these recurrences guides decision making for potential focal salvage treatments. The aim of this study was to determine the positive predictive value (PPV) of combined multiparametric (mp) MRI and prostate specific membrane antigen (PSMA) PET/CT imaging in this setting, with histological conformation using MR-guided targeted biopsies. In 41 patients counseled for focal salvage high dose rate (HDR) brachytherapy, a PPV of 97.6% was found for combined mp-MRI and PSMA PET/CT. Therefore, biopsies can safely be omitted in these patients. Abstract Radiorecurrent prostate cancer is conventionally confirmed using systematic and/or targeted biopsies. The availability of multiparametric (mp) MRI and prostate specific membrane antigen (PSMA) PET/CT has increased diagnostic accuracy. The objective was to determine the positive predictive value (PPV) of combined mp-MRI and PSMA PET/CT and whether pathology verification with MR-targeted biopsies remains necessary for patients with radiorecurrent prostate cancer. Patients with locally recurrent prostate cancer who were referred for 19 Gy single-dose MRI-guided focal salvage high dose rate (HDR) brachytherapy between 2015 and 2018 were included in the current analysis. Patients were selected if they underwent pre-biopsy mp-MRI and PSMA PET/CT. Based on these images, lesions suspect for isolated tumor recurrence were transperineally biopsied using transrectal ultrasound fused with MRI. A total of 41 patients were identified from the database who underwent cognitive targeted (n = 7) or MRI/PSMA-transrectal ultrasound (TRUS) fused targeted (n = 34) biopsies. A total of 40 (97.6%) patients had positive biopsies for recurrent cancer. Five patients initially had negative biopsies (all MRI/PSMA-TRUS fusion targeted), four of whom recurrence was confirmed after a re-biopsy. One (2.4%) patient refused re-biopsy, leading to a positive predictive value (PPV) for combined imaging of 97.6%. Biopsies can therefore safely be withheld when the results of the combined mp-MRI and PSMA PET/CT are conclusive, avoiding an unnecessary invasive and burdensome procedure.
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Griffiths GL, Vasquez C, Escorcia F, Clanton J, Lindenberg L, Mena E, Choyke PL. Translating a radiolabeled imaging agent to the clinic. Adv Drug Deliv Rev 2022; 181:114086. [PMID: 34942275 PMCID: PMC8889912 DOI: 10.1016/j.addr.2021.114086] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/30/2021] [Accepted: 12/16/2021] [Indexed: 02/03/2023]
Abstract
Molecular Imaging is entering the most fruitful, exciting period in its history with many new agents under development, and several reaching the clinic in recent years. While it is unusual for just one laboratory to take an agent from initial discovery through to full clinical approval the steps along the way are important to understand for all interested participants even if one is not involved in the entire process. Here, we provide an overview of these processes beginning at discovery and preclinical validation of a new molecular imaging agent and using as an exemplar a low molecular weight disease-specific targeted positron emission tomography (PET) agent. Compared to standard drug development requirements, molecular imaging agents may benefit from a regulatory standpoint from their low mass administered doses, they nonetheless still need to go through a series of well-defined steps before they can be considered for Phase 1 human testing. After outlining the discovery and preclinical validation approaches, we will also discuss the nuances of Phase 1, Phase 2 and Phase 3 studies that may culminate in an FDA general use approval. Finally, some post-approval aspects of novel molecular imaging agents are considered.
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Affiliation(s)
- Gary L. Griffiths
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Frederick, MD
| | - Crystal Vasquez
- Molecular Imaging Branch, National Cancer Institute, Bethesda, MD
| | - Freddy Escorcia
- Molecular Imaging Branch, National Cancer Institute, Bethesda, MD
| | | | - Liza Lindenberg
- Molecular Imaging Branch, National Cancer Institute, Bethesda, MD
| | - Esther Mena
- Molecular Imaging Branch, National Cancer Institute, Bethesda, MD
| | - Peter L. Choyke
- Molecular Imaging Branch, National Cancer Institute, Bethesda, MD
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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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Kalapara AA, Ballok ZE, Ramdave S, O'Sullivan R, Ryan A, Konety B, Grummet JP, Frydenberg M. Combined Utility of 68Ga-Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography and Multiparametric Magnetic Resonance Imaging in Predicting Prostate Biopsy Pathology. Eur Urol Oncol 2021; 5:314-320. [PMID: 33741337 DOI: 10.1016/j.euo.2021.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 01/29/2021] [Accepted: 02/19/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND 68Gallium-labelled prostate-specific membrane antigen positron emission tomography (68Ga-PSMA-11 PET) is a valuable staging tool, but its utility in characterising primary prostate cancer remains unclear. The maximum standardised uptake value (SUVmax) is a quantification measure of highest radiotracer uptake within PET-avid lesions. OBJECTIVE To assess the utility of SUVmax in detecting clinically significant prostate cancer (csPCa) on biopsy alone and in combination with multiparametric magnetic resonance imaging (mpMRI). DESIGN, SETTING, AND PARTICIPANTS This was a retrospective analysis of 200 men who underwent 68Ga-PSMA-11 PET/CT, mpMRI, and transperineal template prostate biopsy between 2016 and 2018. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary and secondary outcomes were detection of grade group (GG) 3-5 and GG 2-5 prostate cancer, respectively. We used the Mann-Whitney U test to compare SUVmax by GG, and calculated sensitivity and specificity for csPCa detection via 68Ga-PSMA-11 PET/CT, mpMRI, and both. Multivariable logistic regression analyses were used to identify predictors of csPCa on biopsy. RESULTS AND LIMITATIONS The median SUVmax was greater for GG 3-5 tumours (6.40, interquartile range [IQR] 4.47-11.0) than for benign and GG 1-2 tumours (3.14, IQR 2.55-3.91; p < 0.001). The median SUVmax was greater for GG 3 (5.70, IQR 3.68-8.67) than for GG 2 (3.47, IQR 2.70-4.74; p < 0.001). For GG 3-5 disease, sensitivity was 86.5%, 95.9%, and 98.6%, and the negative predictive value (NPV) was 88.4%, 88.5%, and 93.3% using SUVmax ≥4, a Prostate Imaging-Reporting and Data System (PI-RADS) score of 3-5, and both, respectively. This combined model detected more GG 3-5 disease than mpMRI alone (98.6% vs 95.9%; p = 0.04). SUVmax was an independent predictor of csPCa for GG 3-5 disease only (odds ratio 1.27 per unit, 95% confidence interval 1.13-1.45). Our results are limited by the retrospective study design. CONCLUSIONS Greater SUVmax on 68Ga-PSMA-11 PET/CT is associated with detection of GG 3-5 cancer on biopsy. The combination of PI-RADS score and SUVmax provides higher sensitivity and NPV than either alone. 68Ga-PSMA-11 PET/CT may be useful alongside mpMRI in improving risk stratification for localised disease. PATIENT SUMMARY The amount of a radioactive tracer taken up in the prostate during a type of scan called PET (positron emission tomography) can predict whether aggressive prostate cancer is likely to be found on biopsy. This may complement the more usual type of scan, MRI (magnetic resonance imaging), used to detect prostate cancer.
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Affiliation(s)
- Arveen A Kalapara
- Department of Surgery, Monash University, Melbourne, Australia; Australian Urology Associates, Malvern, Australia; Department of Urology, University of Minnesota, Minneapolis, MN, USA.
| | | | - Shakher Ramdave
- Department of Nuclear Medicine & PET, Monash Medical Centre, Bentleigh East, Australia
| | | | | | - Badrinath Konety
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - Jeremy P Grummet
- Department of Surgery, Monash University, Melbourne, Australia; Australian Urology Associates, Malvern, Australia
| | - Mark Frydenberg
- Department of Surgery, Monash University, Melbourne, Australia; Australian Urology Associates, Malvern, Australia; Cabrini Institute, Cabrini Health, Malvern, Australia
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Dahut W, Merlino G, Misteli T. Creating opportunities in cancer research. NATURE CANCER 2021; 2:247-250. [PMID: 35121961 DOI: 10.1038/s43018-021-00187-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- William Dahut
- NCI Center for Cancer Research, National Institutes of Health, Bethesda, MD, USA
| | - Glenn Merlino
- NCI Center for Cancer Research, National Institutes of Health, Bethesda, MD, USA
| | - Tom Misteli
- NCI Center for Cancer Research, National Institutes of Health, Bethesda, MD, USA.
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