The Impact of PSMA PET/CT on Modern Prostate Cancer Management and Decision Making-The Urological Perspective

Abstract

Prostate-specific membrane antigen (PSMA) PET use in prostate cancer treatment has recently become a routinely used imaging modality by urologists. New, established data regarding its performance in different stages of prostate cancer, as well as gaining clinical knowledge with new tracers, drives the need for urologists and other clinicians to improve the utilization of this tool. While the use of PSMA PET/CT is more common in metastatic disease, in which it outperforms classical imaging modalities and drives treatment decisions and adjustments, recently, it gained ground in localized prostate cancer as well, especially in high-risk disease. Still, PSMA PET/CT might reveal lesions within the prostate or possibly locoregional or metastatic disease, not always representing true cancer when utilized in earlier stages of the disease, potentially adding diagnostic burden and changing treatment decisions. As urological treatment options advance toward focal treatments in localized organ-confined prostate cancer, recent reports suggest the utilization of PSMA PET/CT in treatment planning and follow-up and even when choosing active surveillance. This review aims to reveal the current perspective of urologists regarding its daily use.

Keywords: PET CT; PSMA; prostate cancer.

Figure 1

Real-life added value of PSMA PET/CT in prostate cancer treatment.

Figure 2

⁶⁸Ga-PSMA Utilization in Real-Life Prostate Cancer Management: (A) 61 yo patient, PSA-6.1mg/ml. PIRAD 3 lesion detected in MRI. ⁶⁸Ga-PSMA PET CT revealed SUVmax 10.6 uptake on the Rt side. Targeted biopsy detected ISUP3 PCa. (B) 67 yo patient, was referred for surgery due to high volume ISUP2 PCa on prostate biopsy. ⁶⁸Ga-PSMA PET CT uptake in the Lt rib without an apparent lesion on CT, concluded as equivocal when revised. PSA remained undetectable for 1 year following surgery. (C) 72 yo patient, PSA 1.05 mg/ml 4.5 years following external beam radiation therapy. ⁶⁸Ga-PSMA PET/CT imaging revealed Lt side local recurrence. Targeted biopsy detected ISUP3 PCa.