PSMA PET/CT for Primary Staging of PCa - An Updated Overview

A just-published Danish paper:

PSMA PET/CT for Primary Staging of Prostate Cancer - An Updated Overview (2023, Review, Full Text)

"Prostate-specific membrane antigen PET/CT for primary staging of prostate cancer is becoming increasingly popular due to simultaneous assessment of whole-body disease burden, with superior sensitivity and specificity for detecting metastases compared to conventional imaging. PSMA PET in combination with multiparametric MRI (mpMRI) improves the sensitivity of assessment of extra-prostatic extension and seminal vesicle invasion compared to mpMRI alone, and may serve as a second line modality for image-guided biopsy in selected patients with negative mpMRI and/or negative primary biopsies. The superior diagnostic accuracy of PSMA PET/CT affects clinical decision-making with a change of clinical management in one-fourth of patients compared to conventional imaging. However, at present, the effect of implementing PSMA PET/CT for primary staging on patient outcomes is not clear, and prospective studies are warranted. There are several PSMA tracers with similar performance and minor individual pharmacokinetic differences such as higher rate of unspecific bone uptake with 18F-PSMA-1007, but on the other hand, lower urinary excretion, which could give an advantage in the detection of local recurrence. Proper training of the reporting physicians and knowledge of the pitfalls of the specific PSMA tracer used is of utmost importance for high-quality reading. We aim to provide an overview of the current literature and an update on the status of PSMA PET/CT for primary staging of prostate cancer.

-- Introduction
-- Different PSMA Radiotracers
-- PSMA PET for Primary Tumor Staging
-- PSMA PET for Primary Lymph Node Staging
-- PSMA PET for Primary Bone Staging
-- PSMA PET for Clinical Decision-Making
-- PSMA PET in Clinical Guidelines
-- Pitfalls on PSMA PET
-- References

Conclusion

PSMA PET/CT for primary staging of PCa provides superior sensitivity and specificity for detecting lymph node- and bone metastases compared to conventional imaging.

PSMA PET/MRI adds improved sensitivity to the assessment of local tumor extension compared to mpMRI alone, and may serve as a second line modality for image-guided biopsy in selected patients with negative mpMRI and/or negative primary biopsies.

The superior diagnostic accuracy of PSMA PET/CT for primary staging of PCa affects clinical management in one fourth of the patients; however, prospective studies are needed to determine the impact on patient outcome."

Djin

Mumbo said...
Some men still have trouble get MRI’s before biopsy which is crazy, it should be interesting trying to get PSMA scans added to the mix with the obvious cost pushback.

Yes. However they will need to factor in any cost-saving aspects as well: how many cases of metastatic disease can be prevented? Each one entails years of imaging and therapy costs. What diagnostic imaging can it replace (e.g. bone scans?

Djin

If I had just learned my biopsy result--G10--today, the first thing I would want is a PSMA PET scan. Seeing nothing light up outside the prostate would have either corroborated my educated guess that my cancer was prostate-confined or put the kibosh on that hope. It may be that these scans become routinely used (first) for men who are considered high-risk at diagnosis.

We may begin to see the percentage of men diagnosed with mPCa go up, given that PSMA PET is much more sensitive for detecting bone mets at even smaller size than the traditional bone scan. Just as surgery can reveal the presence of higher-grade lesions (Gleason upgrading) within the prostate, a similar "upgrading" of prostate-confined PCa to non-confined, or from localized PCa to mPCa could become more common with better imaging.