Skip to main content

Advertisement

SpringerLink
Log in

Investigating PSMA-PET/CT to resolve prostate MRI PIRADS4-5 and negative biopsy discordance

  • Original Article
  • Published:
World Journal of Urology Aims and scope Submit manuscript

Abstract

Background

To determine the utility of diagnostic 18F-DCPyL PSMA-PET/CT to aid management of men with highly suspicious multiparametric MRI prostate (PIRAD 4–5 lesions) and discrepant negative prostate biopsy.

Methods

A multicentre prospective consecutive case series was conducted (2018–2021), recruiting men with prior mpMRI prostate PIRADS 4–5 lesions and negative prostate biopsy. All men had 18F-DCPyL PSMA-PET/CT with subsequent management based on the concordance between MRI and PET: (1) Concordant lesions were biopsied using in-bore MRI targeting; (2) PSMA-PET/CT avidity without MRI correlate were biopsied using cognitive/software targeting with ultrasound guidance and (3) Patients with negative PET/CT were returned to standard of care follow-up.

Results

29 patients were recruited with 48% (n = 14) having concordant MRI/PET abnormalities. MRI targeted biopsy found prostate cancer in six patients, with grade groups GG3 (n = 1), GG2 (n = 1), GG1 (n = 4) found. Of the 20 men who PSMA-PET/CT avidity and biopsy, analysis showed higher SUVmax (20.1 vs 6.8, p = 0.036) predicted prostate cancer. Of patients who had PSMA-PET avidity without MRI correlate, and those with no PSMA-PET avidity, only one patient was subsequently found to have prostate cancer (GG1). The study is limited by small size and short follow-up of 17 months (IQR 12.5–29.9).

Conclusions

PSMA-PET/CT is useful in this group of men but requires further investigation. Avidity (higher SUVmax) that correlates to the mpMRI prostate lesion should be considered for targeted biopsy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Data availability

This is a small prospective case series - there is no data available to share.

References

  1. Kasivisvanathan V, Rannikko AS, Borghi M, Panebianco V, Mynderse LA, Vaarala MH et al (2018) MRI-targeted or standard biopsy for prostate-cancer diagnosis. N Engl J Med 378(19):1767–1777

    Article  PubMed  PubMed Central  Google Scholar 

  2. Ahmed HU, El-Shater Bosaily A, Brown LC, Gabe R, Kaplan R, Parmar MK et al (2017) Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. The Lancet 389(10071):815–822

    Article  Google Scholar 

  3. Turkbey B, Rosenkrantz AB, Haider MA, Padhani AR, Villeirs G, Macura KJ et al (2019) Prostate imaging reporting and data system version 2.1: 2019 update of prostate imaging reporting and data system version 2. Eur Urol 76(3):340–351

    Article  PubMed  Google Scholar 

  4. Kam J, Yuminaga Y, Krelle M, Gavin D, Koschel S, Aluwihare K et al (2019) Evaluation of the accuracy of multiparametric MRI for predicting prostate cancer pathology and tumour staging in the real world: an multicentre study. BJU Int 124(2):297–301

    Article  PubMed  Google Scholar 

  5. Purysko AS, Bittencourt LK, Bullen JA, Mostardeiro TR, Herts BR, Klein EA (2017) Accuracy and interobserver agreement for prostate imaging reporting and data system, version 2, for the characterization of lesions identified on multiparametric MRI of the prostate. AJR Am J Roentgenol 209(2):339–349

    Article  PubMed  Google Scholar 

  6. Brembilla G, Dell’Oglio P, Stabile A, Damascelli A, Brunetti L, Ravelli S et al (2020) Interreader variability in prostate MRI reporting using prostate imaging reporting and data system version 2.1. Eur Radiol 30(6):3383–3392

    Article  PubMed  Google Scholar 

  7. Moldovan PC, Van den Broeck T, Sylvester R, Marconi L, Bellmunt J, van den Bergh RCN et al (2017) What is the negative predictive value of multiparametric magnetic resonance imaging in excluding prostate cancer at biopsy? A systematic review and meta-analysis from the European Association of Urology Prostate Cancer Guidelines Panel. Eur Urol 72(2):250–266

    Article  PubMed  Google Scholar 

  8. Lo G, Burton KR, Haider MA, Fleshner N, Finelli A, Ghai S (2019) Negative predictive value of prostate multiparametric magnetic resonance imaging among men with negative prostate biopsy and elevated prostate specific antigen: a clinical outcome retrospective cohort study. J Urol 202(6):1159–1165

    Article  PubMed  Google Scholar 

  9. Whish-Wilson T, Costello D, Finch S, Sutherland T, Wong LM (2020) Funding of prostate magnetic resonance imaging leads to fewer biopsies and potential savings to health systems in the management of prostate cancer: funding prostate MRI has potential savings. BJU Int. https://doi.org/10.1111/bju.15231

    Article  PubMed  Google Scholar 

  10. Tsourlakis MC, Klein F, Kluth M, Quaas A, Graefen M, Haese A et al (2015) PSMA expression is highly homogenous in primary prostate cancer. Appl Immunohistochem Amp Mol Morphol AIMM 23(6):449–455

    CAS  Google Scholar 

  11. Hofman MS, Lawrentschuk N, Francis RJ, Tang C, Vela I, Thomas P et al (2020) Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study. The Lancet 395(10231):1208–1216

    Article  CAS  Google Scholar 

  12. Perera M, Papa N, Roberts M, Williams M, Udovicich C, Vela I et al (2020) Gallium-68 prostate-specific membrane antigen positron emission tomography in advanced prostate cancer—updated diagnostic utility, sensitivity, specificity, and distribution of prostate-specific membrane antigen-avid lesions: a systematic review and meta-analysis. Eur Urol 77(4):403–417

    Article  PubMed  Google Scholar 

  13. Perry E, Talwar A, Taubman K, Ng M, Wong LM, Booth R et al (2021) [18F]DCFPyL PET/CT in detection and localization of recurrent prostate cancer following prostatectomy including low PSA < 0.5 ng/mL. Eur J Nucl Med Mol Imaging. https://doi.org/10.1007/s00259-020-05143-9

    Article  PubMed  PubMed Central  Google Scholar 

  14. Koschel S, Taubman K, Sutherland T, Yap K, Chao M, Guerrieri M et al (2021) Patterns of disease detection using [18F]DCFPyL PET/CT imaging in patients with detectable PSA post prostatectomy being considered for salvage radiotherapy: a prospective trial. Eur J Nucl Med Mol Imaging. https://doi.org/10.1007/s00259-021-05354-8

    Article  PubMed  Google Scholar 

  15. Morris MJ, Rowe SP, Gorin MA, Saperstein L, Pouliot F, Josephson D et al (2021) Diagnostic performance of 18F-DCFPyL-PET/CT in men with biochemically recurrent prostate cancer: results from the CONDOR phase III, Multicenter Study. Clin Cancer Res 27(13):3674–3682

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Amin A, Blazevski A, Thompson J, Scheltema MJ, Hofman MS, Murphy D et al (2020) Protocol for the PRIMARY clinical trial, a prospective, multicentre, cross-sectional study of the additive diagnostic value of gallium-68 prostate-specific membrane antigen positron-emission tomography/computed tomography to multiparametric magnetic resonance imaging in the diagnostic setting for men being investigated for prostate cancer. BJU Int 125(4):515–524

    Article  CAS  PubMed  Google Scholar 

  17. Tran V, Hong A, Sutherland T, Taubman K, Lee SF, Lenaghan D et al (2022) PEDAL protocol: a prospective single-arm paired comparison of multiparametric MRI and 18F-DCFPyl PSMA PET/CT to diagnose prostate cancer. BMJ Open 12(9):e061815

    Article  PubMed  PubMed Central  Google Scholar 

  18. Emmett L, Buteau J, Papa N, Moon D, Thompson J, Roberts MJ, et al (2021) The additive diagnostic value of prostate-specific membrane antigen positron emission tomography computed tomography to multiparametric magnetic resonance imaging triage in the diagnosis of prostate cancer (PRIMARY): a prospective multicentre study. Eur Urol Dec 80(6):682–689

  19. Margel D, Bernstine H, Groshar D, Ber Y, Nezrit O, Segal N et al (2021) Diagnostic performance of 68Ga prostate-specific membrane antigen PET/MRI compared with multiparametric MRI for detecting clinically significant prostate cancer. Radiology 301(2):379–386

    Article  PubMed  Google Scholar 

  20. Berger I, Annabattula C, Lewis J, Shetty DV, Kam J, Maclean F et al (2018) 68Ga-PSMA PET/CT vs. mpMRI for locoregional prostate cancer staging: correlation with final histopathology. Prostate Cancer Prostatic Dis 21(2):204–211

    Article  CAS  PubMed  Google Scholar 

  21. Kalapara AA, Nzenza T, Pan HYC, Ballok Z, Ramdave S, O’Sullivan R et al (2020) Detection and localisation of primary prostate cancer using 68 gallium prostate-specific membrane antigen positron emission tomography/computed tomography compared with multiparametric magnetic resonance imaging and radical prostatectomy specimen pathology. BJU Int 126(1):83–90

    Article  CAS  PubMed  Google Scholar 

  22. Panicek DM, Hricak H (2016) How sure are you, doctor? A standardized lexicon to describe the radiologist’s level of certainty. Am J Roentgenol 207(1):2–3

    Article  Google Scholar 

  23. National Cancer Institute. NCI Common Terminology Criteria for Adverse Events 2017. https://evs.nci.nih.gov/ftp1/CTCAE/About.html

  24. Ptasznik G, Papa N, Kelly BD, Thompson J, Stricker P, Roberts MJ, et al (2022) High PSMA PET SUVmax in PI-RADS 4 or 5 men confers a high probability of significant prostate cancer. BJU Int 130 (Suppl 3):5–7

  25. Emmett LM, Papa N, Buteau J, Ho B, Liu V, Roberts M, et al (2022) The PRIMARY Score: Using intra-prostatic PSMA PET/CT patterns to optimise prostate cancer diagnosis. J Nucl Med 63(11):1644–1650. https://doi.org/10.2967/jnumed.121.263448

  26. Meng X, Chao B, Chen F, Huang R, Taneja SS, Deng FM (2021) Followup of men with PI-RADS™ 4 or 5 abnormality on prostate magnetic resonance imaging and nonmalignant pathological findings on initial targeted prostate biopsy. J Urol 205(3):748–754

    Article  PubMed  Google Scholar 

  27. Gaziev G, Wadhwa K, Barrett T, Koo BC, Gallagher FA, Serrao E et al (2016) Defining the learning curve for multiparametric magnetic resonance imaging (MRI) of the prostate using MRI-transrectal ultrasonography (TRUS) fusion-guided transperineal prostate biopsies as a validation tool. BJU Int 117(1):80–86

    Article  PubMed  Google Scholar 

  28. Greer MD, Shih JH, Lay N, Barrett T, Bittencourt L, Borofsky S et al (2019) Interreader variability of prostate imaging reporting and data system version 2 in detecting and assessing prostate cancer lesions at prostate MRI. Am J Roentgenol 212(6):1197–1205

    Article  Google Scholar 

  29. Müller S, Lilleaasen G, Sand TE, Løfsgaard L, Estop-Garanto M, Helgø D et al (2018) Poor reproducibility of PIRADS score in two multiparametric MRIs before biopsy in men with elevated PSA. World J Urol 36(5):687–691

    Article  PubMed  PubMed Central  Google Scholar 

  30. Wegelin O, van Melick HHE, Hooft L, Bosch JLHR, Reitsma HB, Barentsz JO et al (2017) Comparing three different techniques for magnetic resonance imaging-targeted prostate biopsies: a systematic review of in-bore versus magnetic resonance imaging-transrectal ultrasound fusion versus cognitive registration. Is there a preferred technique? Eur Urol 71(4):517–531

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

This clinical trial is supported by Cyclotek (Aust) Pty Ltd and their key partners, the Australian Government as part of its CRC Projects Program, General Electrical Healthcare and Macquarie University. Dr. Samantha Koschel is supported by a Research Training Program Scholarship from the Australian Government. We also acknowledge the support of the St Vincent’s Research Endowment fund.

Author information

Authors and Affiliations

  1. Department of Urology, St Vincent’s Health Melbourne, Melbourne, Australia

    Lih-Ming Wong, Samantha Koschel, Thomas Whish-Wilson & Alexandar Christov

  2. Department of Surgery, University of Melbourne, Melbourne, Australia

    Lih-Ming Wong, Samantha Koschel, Thomas Whish-Wilson, Matthew Farag, Damien Bolton, Homi Zargar, Niall Corcoran & Nathan Lawrentschuk

  3. Department of Urology, Austin Health, Melbourne, Australia

    Lih-Ming Wong, Matthew Farag & Damien Bolton

  4. Department of Urology, Melbourne Health, Melbourne, Australia

    Homi Zargar, Niall Corcoran & Nathan Lawrentschuk

  5. Department of Radiology, St Vincent’s Health Melbourne, Melbourne, Australia

    Lauren Thomas, Elisa Perry, Kim Taubman & Tom Sutherland

  6. Department of Radiology, Melbourne Health, Melbourne, Australia

    Stefan Heinze

  7. Department of Medicine, University of Melbourne, Melbourne, Australia

    Elisa Perry & Tom Sutherland

Authors
  1. Lih-Ming Wong
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Samantha Koschel
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Thomas Whish-Wilson
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Matthew Farag
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Damien Bolton
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Homi Zargar
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Niall Corcoran
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Nathan Lawrentschuk
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Alexandar Christov
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Lauren Thomas
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Elisa Perry
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Stefan Heinze
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Kim Taubman
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Tom Sutherland
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Lih-Ming Wong.

Ethics declarations

Conflict of interest

Cyclotek Pty Ltd have supported authors LMW and TS in this study by providing 18F-DCPyL tracer. However they were not involved in the design, statistical analysis, interpretation of results or writing of manuscript. Unrelated to this project, LMW has received grants from Epworth Medical Foundation and consulting fees from Abbvie and AstraZeneca.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wong, LM., Koschel, S., Whish-Wilson, T. et al. Investigating PSMA-PET/CT to resolve prostate MRI PIRADS4-5 and negative biopsy discordance. World J Urol 41, 463–469 (2023). https://doi.org/10.1007/s00345-022-04243-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00345-022-04243-5

Keywords

Search

Navigation