Prospective comparison of 18F-PSMA-1007 PET/CT, whole-body MRI and CT in primary nodal staging of unfavourable intermediate- and high-risk prostate cancer

Simona Malaspina, Mikael Anttinen, Pekka Taimen, Ivan Jambor, Minna Sandell, Irina Rinta-Kiikka, Sami Kajander, Jukka Schildt, Ekaterina Saukko, Tommi Noponen, Jani Saunavaara, Peter B Dean, Roberto Blanco Sequeiros, Hannu J Aronen, Jukka Kemppainen, Marko Seppänen, Peter J Boström, Otto Ettala, Simona Malaspina, Mikael Anttinen, Pekka Taimen, Ivan Jambor, Minna Sandell, Irina Rinta-Kiikka, Sami Kajander, Jukka Schildt, Ekaterina Saukko, Tommi Noponen, Jani Saunavaara, Peter B Dean, Roberto Blanco Sequeiros, Hannu J Aronen, Jukka Kemppainen, Marko Seppänen, Peter J Boström, Otto Ettala

Abstract

Purpose: To prospectively compare 18F-prostate-specific membrane antigen (PSMA)-1007 positron emission tomography (PET)/CT, whole-body magnetic resonance imaging (WBMRI) including diffusion-weighted imaging (DWI) and standard computed tomography (CT), in primary nodal staging of prostate cancer (PCa).

Methods: Men with newly diagnosed unfavourable intermediate- or high-risk PCa prospectively underwent 18F-PSMA-1007 PET/CT, WBMRI with DWI and contrast-enhanced CT within a median of 8 days. Six readers (two for each modality) independently reported pelvic lymph nodes as malignant, equivocal or benign while blinded to the other imaging modalities. Sensitivity, specificity and accuracy were reported according to optimistic (equivocal lesions interpreted as benign) and pessimistic (equivocal lesions interpreted as malignant) analyses. The reference standard diagnosis was based on multidisciplinary consensus meetings where available histopathology, clinical and follow-up data were used.

Results: Seventy-nine patients completed all the imaging modalities, except for one case of interrupted WBMRI. Thirty-one (39%) patients had pelvic lymph node metastases, which were detected in 27/31 (87%), 14/31 (45%) and 8/31 (26%) patients by 18F-PSMA-1007 PET/CT, WBMRI with DWI and CT, respectively (optimistic analysis). In 8/31 (26%) patients, only 18F-PSMA-1007 PET/CT detected malignant lymph nodes, while the other two imaging modalities were reported as negative. At the patient level, sensitivity and specificity values for 18F-PSMA-1007 PET/CT, WBMRI with DWI and CT in optimistic analysis were 0.87 (95%CI 0.71-0.95) and 0.98 (95%CI 0.89-1.00), 0.37 (95%CI 0.22-0.55) and 0.98 (95%CI 0.89-1.00) and 0.26 (95%CI 0.14-0.43) and 1.00 (95%CI 0.93-1.00), respectively.

Conclusion: 18F-PSMA-1007 PET/CT showed significantly greater sensitivity in nodal staging of primary PCa than did WBMRI with DWI or CT, while maintaining high specificity.

Clinical trial registration: Clinicaltrials.gov ID: NCT03537391.

Keywords: 18F-PSMA-1007 PET/CT; CT; Lymph node metastasis; Primary staging; Prostate cancer; WBMRI.

Conflict of interest statement

The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Imaging and histopathological findings of patient 48. 18F-PSMA-1007 PET/CT clearly identified one pelvic lymph node metastasis (short diameter: 6 mm) on the right (a–b) which was retrospectively identified by CT (c) and WBMRI (d). Histopathological examination confirmed one lymph node metastasis on the right (maximum diameter 7 mm) with intense PSMA and pan-cytokeratin staining in immunohistochemistry (E). On the other hand, 18F-PSMA-1007 PET/CT did not detect another lymph node metastasis found in histopathological examination on the left (maximum diameter: 8,5 mm, f). This lymph node showed less intense immunohistochemical PSMA staining when compared to one on the right. Boxed areas in low magnification images are shown in high magnification images

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