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Shanmugasundaram R, Saad J, Heyworth A, Wong V, Pelecanos A, Arianayagam M, Canagasingham B, Ferguson R, Goolam AS, Khadra M, Kam J, Ko R, McCombie S, Varol C, Winter M, Mansberg R, Nguyen D, Bui C, Loh H, Le K, Roberts MJ. Intra-individual comparison of prostate-specific membrane antigen positron emission tomography/computed tomography versus bone scan in detecting skeletal metastasis at prostate cancer diagnosis. BJU Int 2024; 133 Suppl 3:25-32. [PMID: 37943964 DOI: 10.1111/bju.16115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVES To compare the diagnostic performance and radiological staging impact of 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) compared to 99 Tc whole-body bone scan (WBBS) for the detection of skeletal metastasis in the primary staging of prostate cancer (PCa). PATIENTS AND METHODS A prospective institutional database was retrospectively examined for patients who underwent both PSMA PET and WBBS within a 1 week interval for PCa primary staging. Lesions were categorised as 'negative', 'equivocal', or 'definite' based on nuclear medicine physician interpretation. Metastatic burden was characterised for each imaging modality according to three groups: (i) local disease (no skeletal metastases), (ii) oligometastatic disease (three or fewer skeletal metastases), or (iii) polymetastatic disease (more than three skeletal metastases). RESULTS There were 667 patients included. The median (interquartile range) prostate-specific antigen level was 9.2 (6.2-16) ng/mL and 60% of patients were high risk according to a modified D'Amico risk classification. The overall distribution of skeletal metastasis detection changed across the two scans overall (P = 0.003), being maintained within high-risk (P = 0.030) and low-risk (P = 0.018) groups. PSMA PET/CT identified more definite skeletal metastases compared to WBBS overall (10.3% vs 7.3%), and according to risk grouping (high: 12% vs 9%, intermediate: 4% vs 1%). Upstaging was more common with PSMA PET/CT than WBBS (P = 0.001). The maximum standardised uptake value (SUVmax ) of the primary tumour was associated with upstaging of skeletal metastases on PSMA PET/CT (P = 0.025), while age was associated with upstaging on WBBS (P = 0.021). The SUVmax of the primary tumour and metastases were both higher according to extent of metastatic disease (P = 0.001 and P < 0.001, respectively). CONCLUSIONS More skeletal metastases were detected with PSMA PET/CT than WBBS, resulting in a higher upstaging rate mostly in high-risk patients. The SUVmax of the primary tumour and metastases was associated with upstaging.
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Affiliation(s)
- Ramesh Shanmugasundaram
- Nepean Urology Research Group, Kingswood, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Jeremy Saad
- Nepean Urology Research Group, Kingswood, New South Wales, Australia
| | - Ash Heyworth
- Department of Nuclear Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Veronica Wong
- University of Sydney, Sydney, New South Wales, Australia
- Department of Nuclear Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Anita Pelecanos
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Mohan Arianayagam
- Nepean Urology Research Group, Kingswood, New South Wales, Australia
| | | | - Richard Ferguson
- Nepean Urology Research Group, Kingswood, New South Wales, Australia
| | | | - Mohamed Khadra
- Nepean Urology Research Group, Kingswood, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan Kam
- Nepean Urology Research Group, Kingswood, New South Wales, Australia
| | - Raymond Ko
- Nepean Urology Research Group, Kingswood, New South Wales, Australia
| | - Stephen McCombie
- Nepean Urology Research Group, Kingswood, New South Wales, Australia
- Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- University of Western Australia, Crawley, Western Australia, Australia
| | - Celi Varol
- Nepean Urology Research Group, Kingswood, New South Wales, Australia
| | - Matthew Winter
- Nepean Urology Research Group, Kingswood, New South Wales, Australia
| | - Robert Mansberg
- University of Sydney, Sydney, New South Wales, Australia
- Department of Nuclear Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Diep Nguyen
- University of Sydney, Sydney, New South Wales, Australia
- Department of Nuclear Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Chuong Bui
- Department of Nuclear Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Han Loh
- University of Sydney, Sydney, New South Wales, Australia
- Department of Nuclear Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Ken Le
- Department of Nuclear Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Matthew J Roberts
- Nepean Urology Research Group, Kingswood, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
- Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- University of Queensland Centre for Clinical Research, Herston, Queensland, Australia
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Goolam AS, la Rosa AHD, Manoharan M. Surgical Management of Organ-Confined Prostate Cancer with Review of Literature and Evolving Evidence. Indian J Surg Oncol 2018; 9:225-231. [PMID: 29887706 DOI: 10.1007/s13193-016-0594-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 06/16/2016] [Indexed: 11/29/2022] Open
Abstract
Prostate cancer is the most common solid organ malignancy in men in the USA with an annual incidence of 105 and an annual mortality rate of 19 per 100,000 people. With the advent of PSA screening, the majority of prostate cancer diagnosed is organ confined. Recent studies including the SPCG-4 and PIVOT trials have demonstrated a survival benefit for those undergoing active treatment for localized prostate cancer. The foremost surgical option has been radical prostatectomy (RP). The gold standard has been open radical retropubic prostatectomy (RRP); however, minimally invasive approaches including laparoscopic and robotic approaches are commonplace and increasing in popularity. We aim to describe the surgical options for the treatment of localized prostate cancer by reviewing the literature. A review of the literature was undertaken using MEDLINE and PubMed. Articles addressing the topic of radical prostatectomy by open, laparoscopic and robotic approaches were selected. Studies comparing the different modalities were also identified. These articles were reviewed for data pertaining to perioperative, oncological and functional outcomes. There is a paucity of randomized studies comparing the three modalities. The published data has demonstrated a benefit in favour of robotically assisted laparoscopic prostatectomy (RALP) over laparoscopic radical prostatectomy (LRP) and traditional open RRP in perioperative outcomes. When reviewing the best-reported outcomes for RALP compared to LRP and RRP, operative times are lower (105 vs. 138 vs. 138 min), estimated blood loss rates are lower (111 vs. 200 vs. 300 ml) and blood transfusion rates are lower as in the length of stay (1 vs. 2 vs. 2.3 days) and overall complication rates (4.3 vs. 5 vs. 20%). Similarly, when reviewing functional outcomes, RALP compared to LRP was not inferior. At 12 months, the reported continence was 97 vs. 94 vs. 89% and potency was 94 vs. 77 vs. 90%. In comparative studies, however, these differences did not always meet statistical significance. With respect to oncological outcomes, there was no clear evidence of superiority of one modality over another. RALP is now the most common modality for surgical treatment of organ-confined prostate cancer. Individual series appear to support better perioperative outcomes and perhaps quicker return to functional outcomes. There does not appear to be a clear advantage to date in oncological parameters; however, RALP does not appear to be inferior to either LRP or RRP. It is anticipated that further high quality randomized studies will shed more light on the clinical and statistical significance in the comparison between these modalities.
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Affiliation(s)
- Ahmed Saeed Goolam
- 1Department of Urology, University of Miami Miller School of Medicine, PO Box 016960(M814), Miami, FL 33101 USA
| | - Alfredo Harb-De la Rosa
- 1Department of Urology, University of Miami Miller School of Medicine, PO Box 016960(M814), Miami, FL 33101 USA
| | - Murugesan Manoharan
- Division of Urologic Oncology, Miami Cancer Institute, 8900 N Kendall Drive, Miami, FL 33176 USA
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