Optimized Application of 68Ga-Prostate-Specific Membrane Antigen-617 Whole-Body PET/CT and Pelvic PET/MR in Prostate Cancer Initial Diagnosis and Staging

Chunxia Qin, Yongkang Gai, Qingyao Liu, Weiwei Ruan, Fang Liu, Fan Hu, Xiaoping Zhang, Xiaoli Lan, Chunxia Qin, Yongkang Gai, Qingyao Liu, Weiwei Ruan, Fang Liu, Fan Hu, Xiaoping Zhang, Xiaoli Lan

Abstract

Purpose: To analyze 68Ga-PSMA-617 PET/CT or PET/MR and delayed PET/MR images in patients diagnosed with or suspicion of prostate cancer, and to explore the optimal use of PET/CT and PET/MR for initial diagnosis and staging in prostate cancer. Methods: Images from conventional scan by 68Ga-PSMA whole-body PET/CT or PET/MR followed by delayed pelvic PET/MR were retrospectively analyzed. Prostatic 68Ga-PSMA uptake was measured as SUVmax1 (conventional scan 1 h post injection) and SUVmax2 (delayed scan 3 h post injection). Age, PSA levels, and SUVmax were compared between benign and malignant cases. The correlation of SUVmax1 and SUVmax2 was analyzed. Diagnostic performance was evaluated by ROC analysis. Results: Fifty-six patients with 41 prostate cancers and 15 benign prostate lesions were enrolled. Fifty-three patients had paired conventional and delayed scans. Age, tPSA, fPSA levels, and SUVmax were significantly different between benign and malignant cases. A good correlation was found between SUVmax1 and SUVmax2. There was significant difference between SUVmax1 and SUVmax2 in the malignant group (p = 0.001). SUVmax1 had superior diagnostic performance than SUVmax2, SUVmax difference and PSA levels, with a sensitivity of 85.4%, a specificity of 100% and an AUC of 0.956. A combination of SUVmax1 with nodal and/or distant metastases and MR PI-RADS V2 score had a sensitivity and specificity of 100%. Delayed pelvic PET/MR imaging in 33 patients were found to be redundant because these patients had nodal and/or distant metastases which can be easily detected by PET/CT. PET/MR provided incremental value in 8 patients at early-stage prostate cancer based on precise anatomical localization and changes in lesion signal provided by MR. Conclusion: Combined 68Ga-PSMA whole-body PET/CT and pelvic PET/MR can accurately differentiate benign prostate diseases from prostate cancer and accurately stage prostate cancer. Whole-body PET/CT is sufficient for advanced prostate cancer. Pelvic PET/MR contributes to diagnosis and accurate staging in early prostate cancer. Imaging at about 1 h after injection is sufficient in most patients. ClinicalTrials.gov : NCT03756077. Registered 27 November 2018-Retrospectively registered, https://ichgcp.net/clinical-trials-registry/NCT03756077.

Keywords: 68Ga-PSMA; PET/CT; PET/MR; benign prostatic hyperplasia; prostate cancer; prostatitis.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Qin, Gai, Liu, Ruan, Liu, Hu, Zhang and Lan.

Figures

Figure 1
Figure 1
(A) A 65-year-old man with a total PSA level of > 1,000 ng/L and free PSA > 30 ng/L underwent 68Ga-PSMA PET/MR, which revealed extensive bone metastases but negative uptake of PSMA in the prostate. (B) A 64-year-old man with a total PSA level of 13.9 ng/L and free PSA of 2.15 ng/L underwent 68Ga-PSMA PET/CT, which showed uptake in multiple lymph nodes in the left supraclavicular area, retroperitoneum, and the left iliac chain, but no focal uptake in prostate. Prostate acinar adenocarcinoma with left iliac lymph node metastases (6/6) were histopathologically proved.
Figure 2
Figure 2
(A) A 72-year-old man with a PSA level of 21.26 ng/L underwent 68Ga-PSMA PET/CT and delayed pelvic PET/MR. Positive PSMA uptake was revealed in the left peripheral zone, consistent with the signal change in mpMR. (B) A 68-year-old man with proven prostate cancer in the right lobe underwent PET/MR for staging. Axial T2-weighted image shows an ill-defined hypointense lesion in the right peripheral zone with corresponding hypo-intensity on the apparent diffusion coefficient map. No significant hyperintense signal was observed on DW images (b = 1,000 s/mm2). This was assigned a PI-RADS score of 4, but negative PSMA uptake was observed with diffuse 68Ga-PSMA uptake in the prostate (SUVmax, 4.10). (C) A 71-year-old man with proven prostate cancer after prostate transurethral resection, 68Ga-PSMA PET/CT and pelvic PET/MR were performed for staging. PET/CT revealed only one small lymph node in the left pelvic cavity, which was revealed more clearly on PET/MR, and more lesions were revealed on PET/MR, which were proved to be metastases after surgery.
Figure 3
Figure 3
(A) Scatter diagram of SUVmax from different scanner at different time point. (B) Bland–Altman plots of the differences against the means of SUVmax1 with SUVmax2. (C) Scatter plot and correlation of SUVmax1 and SUVmax2. (D) Scatter plot and correlation of SUVmax1 and fPSA/tPSA.
Figure 4
Figure 4
ROC curves evaluating diagnostic performance of PSA levels (A) and 68Ga-PSMA SUVmax (B).
Figure 5
Figure 5
Diagnostic overview of all patients in this study. LN, lymph node.

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