68Ga-PSMA PET/CT and Prostate Cancer Diagnosis: Which SUVmax Value?

BACKGROUND/AIM

To evaluate the diagnostic accuracy of ⁶⁸Ga-prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) in the diagnosis and staging of prostate cancer (PCa).

PATIENTS AND METHODS

From January 2021 to December 2022, 160 men (median age: 66 years) with PCa (median PSA of 11.7 ng/ml) before prostate biopsy underwent ⁶⁸Ga-PET/CT imaging examinations (Biograph 6; Siemens, Knoxville, TN, USA). The location of focal uptake on ⁶⁸Ga-PSMA PET/TC and standardized uptake values (SUVmax) were reported on a per-lesion basis for each International Society of Urological Pathology (ISUP) grade group (GG) PCa.

RESULTS

Overall, the median intraprostatic ⁶⁸Ga-PSMA SUVmax was 26.1 (range=2.7-164); in the 15 men with not clinically significant PCa (ISUP grade group 1) median SUVmax was 7.5 (range=2.7-12.5). In the 145 men with csPCa (ISUP GG≥2) median SUVmax was 33 (range=7.8-164). A SUVmax cut-off of 8 demonstrated a diagnostic accuracy in the diagnosis of PCa equal to 87.7% vs. 89.3% vs. 100% in the presence of a GG1 vs. GG2 vs. GG≥3 PCa, respectively. In addition, median SUVmax in the bone and node metastases was 52.7 (range=25.3-92.8) and 47 (range=24.5-65), respectively.

CONCLUSION

⁶⁸GaPSMA PET/CT with a SUVmax cut-off of 8 demonstrated a good accuracy in the diagnosis of csPCa (100% in the presence of GG≥3) showing a good cost-benefit ratio as a single procedure for the diagnosis and staging of high-risk PCa.

Clinical Outcomes of Hydrogel Spacer Injection Space OAR in Men Submitted to Hypofractionated Radiotherapy for Prostate Cancer

BACKGROUND/AIM

To evaluate the clinical outcomes of men with prostate cancer (PCa) submitted to hydrogel spacer injection before hypofractionated radiotherapy (HRT).

PATIENTS AND METHODS

From April 2018 to April 2020, 32 patients with clinically localized PCa underwent hydrogel injection Space OAR before HRT to the prostate and seminal vesicle; the prescription dose was 60 Gy in 20 fractions, 5 days/week over 4 weeks. PSA levels, genitourinary (GU) and gastrointestinal (GI) toxicities, and sexual function were prospectively evaluated.

RESULTS

PSA levels at the median follow up of 15 months was 0.52 ng/ml; 28.1% vs. 78.1% patients had GI vs. GU Grade 0 acute toxicity and 93.7% vs. 0% had GI vs. GU Grade 0 late toxicity. Furthermore, 88.1% of patients kept pretreatment sexual potency.

CONCLUSION

The use of the hydrogel Spacer OAR before HRT is useful for reducing acute and late GU and GI toxicities.

Breast cancer bone metastases: an epidemiologic study in selected radiation departments

AIMS

To quantify radiation treatments for bone metastases from breast cancer in three Sicilian provinces (Messina, Catania, Ragusa) with respect to the general population and the incidence and prevalence of breast cancer in this macro-area in a 8-year period.

METHODS

All bone metastasis patients treated using radiotherapy in 8 radiation departments operating in the provinces of Messina, Catania and Ragusa were collected. Among these, metastases from breast carcinoma were analyzed according to year of irradiation. An analysis of breast cancer incidence and prevalence with respect to inhabitants in this macro-area was conducted using literature and census data.

RESULTS

From January 2004 to December 2011, irradiation was delivered in 4419 bone metastasis patients. Among these, 1617 had a primary breast cancer with a median treatment per year of 206.5 (range, 164-251); 211 patients were treated in 2004 and 206 in 2011. In 2004, there were 1,048,957 female residents in the three provinces and 1,065,422 in 2011. The reported breast cancer incidence and prevalence in Sicily was respectively 100.79/100,000 and 908.54/100,000 in 2004 and 108.41/100,000 and 1091.29/100,000 in 2010.

CONCLUSIONS

There has been an increase in both incidence and prevalence of breast cancer in Sicily. Nevertheless, it seems that there was no increment in skeletal-related events requiring irradiation in such patients in eastern Sicily radiation departments.

Erectile dysfunction following hydrogel injection and hypofractionated radiotherapy for prostate cancer: Our experience in 56 cases

INTRODUCTION

The incidence of erectile dysfunction (ED) in men with organ-confined prostate cancer (PCa) submitted to hypofractionated radiotherapy (HRT) has been prospectively evaluated.

MATERIALS AND METHODS

From April 2018 to September 2020, 56 patients (median age 70 years) with cT1c PCa were treated by HRT directed to the prostate and seminal vesicle. Median PSA was 8.3 ng/ml; 20 patients (35.7%) vs. 28 (50%) vs. 8 (22.3%) had a PCa Grade Group 1 vs. 2 vs. 3, respectively. All patients underwent hydrogel injection of Space OAR and intraprostatic fiducials before HRT. The prescription dose was 60 Gy in 20 fractions 5 days/week over 4 weeks. During the follow up, PSA, genitourinary (GU) and gastrointestinal (GI) toxicities were evaluated. The sexual function was evaluated by International Index of Erectile Function - 5 (IIEF-5) before, 6 and 18 months from HRT; 32/56 (57.1%) men referred a normal sexual activity before HRT (median IIEF-5 score: 22).

RESULTS

Median PSA level at median follow up of 18 months was 0.92 ng/ml and none used adjuvant therapy. One man (1.8%) referred a tardive grade 1 GU complication. At a median follow up of 6 and 18 months, 20/32 (62.5%) kept pretreatment sexual potency (median IIEF-5 score: 21). The 12/32 men who worsened the sexual function following HRT had a median age higher than patients without ED (78 vs. 67 years).

CONCLUSIONS

The use of hydrogel injection and intraprostatic fiducials followed by HRT allowed to kept pretreatment sexual potency in 62.5% of the cases.

Stereotactic Body Radiotherapy for Lymph-Nodal Oligometastatic Prostate Cancer: A Multicenter Retrospective Experience

Background: The favorable role of SBRT for lymph-nodal oligometastases from prostate cancer has been reported by several retrospective and prospective experiences, suggesting a more indolent natural history of disease when compared to patients with bone oligometastases. This retrospective multicenter study evaluates the outcomes of a cohort of patients treated with stereotactic body radiotherapy for lymph-nodal oligometastases. Methods: Inclusion criteria were up to five lymph-nodal oligometastases detected either with Choline-PET or PSMA-PET in patients naïve for ADT or already ongoing with systemic therapy and at least 6 Gy per fraction for SBRT. Only patients with exclusive lymph-nodal disease were included. The primary endpoint of the study was LC; a toxicity assessment was retrospectively performed following CTCAE v4.0. Results: A total of 100 lymph-nodal oligometastases in 69 patients have been treated with SBRT between April 2015 and November 2022. The median age was 73 years (range, 60-85). Oligometastatic disease was mainly detected with Choline-PET in 47 cases, while the remaining were diagnosed using PSMA-PET, with most of the patients treated to a single lymph-nodal metastasis (48/69 cases), two in 14 cases, and three in the remaining cases. The median PSA prior to SBRT was 1.35 ng/mL (range, 0.3-23.7 ng/mL). Patients received SBRT with a median total dose of 35 Gy (range, 30-40 Gy) in a median number of 5 (range, 3-6) fractions. With a median follow-up of 16 months (range, 7-59 months), our LC rates were 95.8% and 86.3% at 1 and 2 years. DPFS rates were 90.4% and 53.4%, respectively, at 1 and 2 years, with nine patients developing a sequential oligometastatic disease treated with a second course of SBRT. Polymetastatic disease-free survival (PMFS) at 1 and 2 years was 98% and 96%. Six patients needed ADT after SBRT for a median time of ADT-free survival of 15 months (range, 6-22 months). The median OS was 16 months (range, 7-59) with 1- and 2-year rates of both 98%. In multivariate analysis, higher LC rates and the use of PSMA-PET were related to improved DPFS rates, and OS was significantly related to a lower incidence of distant progression. No G3 or higher adverse events were reported. Conclusions: In our experience, lymph-nodal SBRT for oligometastatic prostate cancer is a safe and effective option for ADT delay with no severe toxicity.

Image-guided moderately hypofractionated radiotherapy for localized prostate cancer: a multicentric retrospective study (IPOPROMISE)

BACKGROUND

Moderate hypofractionated radiotherapy is a treatment option for the cure of localized prostate cancer (PCa) patients based on the results of randomized prospective trials, but there is a clinical concern about the relatively short length of follow-up, and real-world results on outcome and toxicity based on cutting-edge techniques are lacking. The objective of this study is to present the long-term results of a large multicentric series.

MATERIALS AND METHODS

We retrospectively evaluated 1325 PCa patients treated with daily volumetric image-guided hypofractionated radiotherapy between 2007 and 2020 in 16 Centers. For survival endpoints, we used Kaplan-Meier survival curves and fitted univariate and multivariable Cox's proportional hazards regression models to study the association between the clinical variables and each survival type.

RESULTS

At the end of the follow-up, 11 patients died from PCa. The 15-year values of cancer-specific survival (CSS) and biochemical relapse-free survival (b-RFS) were 98.5% (95%CI 97.3-99.6%) and 85.5% (95%CI 81.9-89.4%), respectively. The multivariate analysis showed that baseline PSA, Gleason score, and the use of androgen deprivation therapy were significant variables for all the outcomes. Acute gastrointestinal (GI) and genitourinary (GU) toxicities of grade ≥ 2 were 7.0% and 16.98%, respectively. The 15-year late grade ≥ 2 GI and GU toxicities were 5% (95%CI 4-6%) and 6% (95%CI 4-8%), respectively.

CONCLUSION

Real-world long-term results of this multicentric study on cutting-edge techniques for the cure of localized PCa demonstrated an excellent biochemical-free survival rate of 85.5% at 15 years, and very low rates of ≥ G3 late GU and GI toxicity (1.6% and 0.9% respectively), strengthening the results of the available published trials.

Ladies project: large database in endometrial cancers for a personalized treatment

PURPOSE

To compare Italian use with current international guidelines and to evaluate oncological outcomes and toxicity patterns of adjuvant radiation therapy (RT) for endometrial cancer (EC) in Italian women.

MATERIALS AND METHODS

To conduct a retrospective multicentre Italian study a large database was set up. Inclusion criteria were: accrual between 2010 and 2020, treatment with surgery, post-operative external beam RT (EBRT) and/or interventional radiotherapy (IRT) associated or not with adjuvant chemotherapy. Oncological outcomes, acute and late toxicities were analysed according to RT schedule and risk group.

RESULTS

A total of 1848 patients, from 16 Italian RT centres were enrolled (median age 65 years, range 27-88). All patients received post-operative RT associated with chemotherapy in 31%. Patients were stratified on the basis of standard risk factors (Bosse et al. in Eur J Cancer 51:1742-50, 2015). After merging intermediate and high-intermediate risk classes into one intermediate group and including advanced and oligometastatic disease in the high-risk group, the low-risk group encompassed 124 patients, the intermediate-risk 1140, and the high risk 576. No low-risk patient developed local relapse (LR). Multivariate analysis showed that intermediate risk patients had a 2.5-fold increased risk of LR if treated with IRT alone vs EBRT-IRT boost. RT schedule did not impact significantly on LR in high risk patients. All acute toxicity parameters were highest in patients who received EBRT with simultaneous integrated boost (EBRT-SIB) and lowest in patients who received only IRT (p < 0.0001). Late toxicity was highest patients who received EBRT-SIB and lowest in those who were given EBRT with sequential boost (p < 0.0001).

CONCLUSIONS

This retrospective study showed that Italian administration of adjuvant RT for EC is in accordance with current international guidelines. IRT alone for low-risk patients and EBRT associated with vaginal IRT remain standard adjuvant approaches for EC.

Salvage Radiotherapy PSMA PET/CT-guided in Men With PSA Recurrence

BACKGROUND/AIM

To evaluate the clinical outcome in men with recurrent prostate cancer (PCa) treated by salvage radiotherapy (sRT) prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT)-guided.

PATIENTS AND METHODS

From January 2021 to January 2023, 33 patients who previously underwent definitive/systemic therapy were submitted to sRT PSMA PET/CT-guided for PCa recurrence: 16 (48.5%) on the prostate bed (PB), 12 (36.4%) on the lymph node (LN) and five (15.1%) on the bone. The median PSA value was 3.3 ng/ml (range=0.3-15.5 ng/ml): 0.2-0.5 ng/ml (18.2% cases), 0.51-1 ng/ml (39.4% cases) and >1 ng/ml (42.4% cases). Median 18F PSMA PET/CT standardized uptake value (SUVmax) was evaluated on PB, vs. LN vs. bones PCa recurrences and was equal to 12.5 vs. 19.0 vs. 30.1, respectively.

RESULTS

Overall, at a median follow up of 12 months, 23/33 patients (69.7%) had local control without distant progression (PSA and SUVmax evaluation): 14/16 (87.5%) vs. 7/12 (58.3%) vs. 2/5 (40%) underwent sRT on the PB vs. LN vs. bone metastases, respectively.

CONCLUSION

PSMA PET/CT allows to perform sRT early in men with PCa recurrence and low PSA values obtaining a complete clinical response in approximately 70% of the cases one year from treatment.

Targeted prostate biopsy: 68Ga-PSMA PET/CT vs. mpMRI in the diagnosis of prostate cancer

Introduction: To evaluate the diagnostic accuracy of 68Ga-prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomog-raphy (PET/CT) vs. multiparametric magnetic resonance imag-ing (mpMRI) targeted biopsy (TPBx) in the diagnosis of clinical-ly significant prostate cancer (csPCa: Grade Group ≥ 2). Materials and methods: From January 2021 to June 2022, 100 patients (median age: 66 years) with negative digital rectal examination underwent transperineal prostate biopsy for abnor-mal PSA values (median 7.5 ng/ml). Before prostate biopsy, all patients underwent mpMRI and 68Ga-PET/CT examinations and mpMRI (PI-RADS version 2 ≥ 3) or 68Ga-PET/CT index lesions suspicious for cancer (SUVmax > 5 g/ml) underwent cognitive targeted cores (mpMRI-TPBx and PSMA-TPBx: four cores) com-bined with extended systematic prostate biopsy (eSPBx: median 18 cores). The procedure was performed transperineally using a tru-cut 18-gauge needle under sedation and antibiotic prophy-laxis. Results: PCa was found in 58/100 (58.0%) men; in detail, 44/58 (75.9%) were csPCa; mpMRI and 68Ga-PSMA showed 66/100 (66%) and 62/100 (60%) lesions suspicious for PCa, respective-ly. 68Ga-PSMA-TPBx vs. mpMRI-TPBx vs. eSPBx diagnosed 42 (95.4%) vs. 36 (81.8%) vs. 30 (68.2%) csPCa, respectively; mpMRI-TPBx vs. 68Ga-PSMA-TPBx showed a diagnostic accuracy of 76.9% vs. 84.9% in diagnosing csPCa. Conclusions: 68GaPSMA PET/CT TPBx demonstrated good accuracy in the diagnosis of csPCa, which was not inferior to mpMRI TPBx (84.9% vs. 76.9%) improving the detection rate for cancer of systematic biopsy.

Hypofractionated radiotherapy in elderly patients (≥75 years) affected by localized prostate cancer: a multicenter retrospective analysis from the IPOPROMISE study

BACKGROUND

Prostate Cancer (PCa) is the second leading cause of cancer death in the elderly (≥75 years). There is currently little data on hypofractionated radiotherapy in older patients affected by localized PCa. We present the long-term results of hypofractionated radiotherapy in elderly patients with localized PCa from the IPOPROMISE database.

MATERIALS AND METHODS

retrospective analysis of 719 PCa elderly (≥75 years) patients treated with daily volumetric image-guided hypofractionated radiotherapy between 2007 and 2020. For survival endpoints, we used Kaplan-Meier survival curves and univariate and multivariable Cox's proportional hazards regression models.

RESULTS

Median age at PCa diagnosis was 78.4 years (interquartile [IQR], 76.8-80.3 years), 74% of patients had a modified Charlson co-morbidity index (elderly-PCa-CCI, (e-PCCI)) of 0. Based on NCCN risk grouping, 399 patients (55.5%) were affected by unfavorable to very high-risk disease. Median follow-up was 4.2 years (IQR 2.4-6.4 years). 31/719 (4.3%) patients died from any cause. At 5 years, overall survival (OS), cancer-specific survival (CSS), and metastasis-free survival were 95.6% (95% CI 93.4-97.1%), 99.2% (95%CI 97.9-99.7%), and 97.3% (95% CI 95.1-98.5%), respectively. In multivariate analysis, baseline PSA, and Gleason score were associated with MFS. On univariate analysis, e-PCCI ≥ 2 was associated with OS (p = 0.02). The 5-year freedom from late grade ≥2 gastrointestinal (GI) and genitourinary (GU) toxicity were 95.1% (95% CI 93.0-96.5%) and 96.7% (95% CI 93.7-97.1%), respectively.

CONCLUSIONS

Our results represent a valuable add-on to the current literature, confirming the prominent role of radiotherapy in the cure of elderly fit patients affected by localized disease.