PSMA PET in Imaging Prostate Cancer

Ioannis Tsechelidis, Alexis Vrachimis, Ioannis Tsechelidis, Alexis Vrachimis

Abstract

After prostate malignancy diagnosis, precise determination of disease extent are fundamental steps for tailored made therapy. The earlier the diagnosis of the burden of the disease, the longer the survival in many cases. National and international guidelines are based on "classic" imaging technics combining radiological and nuclear medicine scans like CT, MRI and bone scintigraphy (BS). The most recent nuclear medicine development is the prostate specific membrane antigen (PSMA) PET and is emerging as the most promising tool of medical imaging, gaining ground every day. Nevertheless, the different onset among multiple studies fails to establish a worldwide admission and incorporation of this technique in guidelines and its position in workaday medical algorithms. It seems that the medical community agrees not to utilize PSMA PET for low-risk patients; intense debate and research is ongoing for its utility in intermediate risk patients. Contrariwise, in high-risk patients PSMA PET is confirmed outperforming CT and BS combined. Additionally, irrespectively to their castration status, patients with biochemical failure should be referred for PSMA PET. Even though PSMA PET reveals more extended disease than expected or exonerates equivalent lesions, thus impacting treatment optimization. Studies being in progress and future trials with clarify whether PSMA PET will be the new gold standard technic for specific groups of patients.

Keywords: PET/CT; biochemical failure (BF); restaging; staging; theranostics.

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 © 2022 Tsechelidis and Vrachimis.

Figures

Figure 1
Figure 1
Patient suffering from prostate cancer is referred for bone scintigraphy after biochemical failure, detecting multiple sites of osteoblastic activity corresponding to multiple bone lesions (A). Within one week the patient also underwent a 11C-Choline PET/CT in order to exclude visceral spread (B) for treatment planning. Apart from additional bone secondaries, a common iliac lymph nodal lesion right (arrow) is detected (maximum intensity projection (MIP); (B). However, the true spread of the disease is much more extended by 68Ga-PSMA PET (MIP); (C) [republished with permission of the Hellenic Journal of Nuclear Medicine (7)].
Figure 2
Figure 2
Radical prostatectomy in 2004 due to adenocarcinoma. Salvage radiotherapy due to biochemical recurrence in 2007 with negative restaging on conventional imaging. In 2013, new PSA rise without lesions on restaging with CT, MRI and bone scintigraphy; intermittent androgen-deprivation therapy. Patient referred for 68Ga-PSMA-11 PET/CT in 2016 (not available) and 2017 (maximum intensity projection (MIP); (A) negative for PSMA-expressing lesions (PSA levels at 0.8 and 1.0ng/mL, respectively). Due to further increase of PSA (1.1ng/mL) an 18F-PSMA-1007 PET/CT examination took place in 2018. Images B - E show 18F-PSMA -1007 PET/CT of the same patient (B): MIP, (C): axial cross section PET, (D): axial cross section CT, (E): fused axial PET/CT image). Arrows show unequivocal PSMA-expression corresponding to local recurrence; the quality of the image is not biased by PSMA-detection in the ureters or inside the bladder (in comparison to A) [republished with permission of the Hellenic Journal of Nuclear Medicine (7)].

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