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. 2025 Jul;35(7):4043-4054.
doi: 10.1007/s00330-025-11358-x. Epub 2025 Jan 24.

Discordance between prostate MRI and PSMA-PET/CT: the next big challenge for primary prostate tumor assessment?

Sungmin Woo  1 , Anton S Becker  2 , Doris Leithner  2 , Marius E Mayerhoefer  2 , Kent P Friedman  3 , Angela Tong  4 , David R Wise  5 , Samir S Taneja  6 , Michael J Zelefsky  7 , Hebert A Vargas  2
Affiliations

Discordance between prostate MRI and PSMA-PET/CT: the next big challenge for primary prostate tumor assessment?

Sungmin Woo et al. Eur Radiol. 2025 Jul.

Abstract

Objectives: An increasing number of patients with prostate cancer (PCa) undergo assessment with magnetic resonance imaging (MRI) and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT). This offers comprehensive multimodality staging but can lead to discrepancies. The objective was to assess the rates and types of discordance between MRI and PSMA-PET/CT for primary PCa assessment.

Materials and methods: Consecutive men diagnosed with intermediate and high-risk PCa who underwent MRI and PSMA-PET/CT in 2021-2023 were retrospectively included. MRI and PSMA-PET/CT were interpreted using PI-RADS v2.1 and PRIMARY scores. Discordances between the two imaging modalities were categorized as "minor" (larger or additional lesion seen on one modality) or "major" (positive on only one modality or different index lesions between MRI and PSMA-PET/CT) and reconciled using radical prostatectomy or biopsy specimens.

Results: Three hundred and nine men (median age 69 years, interquartile range (IQR) 64-75) were included. Most had Gleason Grade Group ≥ 3 PCa (70.9% (219/309)). Median PSA was 9.0 ng/mL (IQR 5.6-13.6). MRI and PSMA-PET/CT were concordant in 157/309 (50.8%) and discordant in 152/309 (49.1%) patients; with 39/152 (25.7%) major and 113/152 (74.3%) minor discordances. Of 27 patients with lesions only seen on MRI, 85.2% (23/27) were clinically significant PCa (csPCa). Of 23 patients with lesions only seen on PSMA-PET/CT, 78.3% (18/23) were csPCa. Altogether, lesions seen on only one modality were csPCa in 80.0% (36/45).

Conclusion: MRI and PSMA-PET/CT were discordant in half of patients for primary PCa evaluation, with major discrepancies seen in roughly one out of eight patients.

Key points: Question While both MRI and PSMA-PET/CT can be used for primary tumor assessment, the discordances between them are not well established. Findings MRI and PSMA-PET/CT were discordant in about half of the patients. Most prostate lesions seen on only one modality were significant cancer. Clinical relevance MRI and PSMA-PET/CT are often discordant for assessing the primary prostate tumor. Using both modalities for primary prostate tumor evaluation can provide complementary information that may substantially impact treatment planning.

Keywords: Discordance; Magnetic resonance imaging; Positron-emission tomography; Prostate-specific membrane antigen; Prostatic neoplasms.

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Conflict of interest statement

Compliance with ethical standards. Guarantor: The scientific guarantor of this publication is Sungmin Woo. Conflict of interest: The authors of this manuscript declare relationships with the following companies: Marius E. Mayerhoefer received honoraria for lectures from Siemens, GE, and BM but unrelated to the current work. Kent P. Friedman is a co-investigator on “Optimizing timing of rhPSMA-7.3 (18F), for assessing site(s) of recurrent disease following radical prostatectomy” (PI Herbert Lepor) but does not receive any salary support and is unrelated to the current work. David R. Wise has received consulting fees from Leap Therapeutics, Foundation Medicine, Pfizer, Janssen, Sanofi, Lilly, Labcorp, Myovant, Bayer, AstraZeneca, Accutar and has received travel funding from Pfizer and Bayer but unrelated to the current work. The other authors have nothing to disclose. Statistics and biometry: No complex statistical methods were necessary for this paper. Informed consent: Written informed consent was not required for this study because of the retrospective design and was waived by the Institutional Review Board. Ethical approval: Institutional Review Board approval was obtained. Study subjects or cohorts overlap: No overlap with prior studies. Methodology: Retrospective Cross-sectional study Performed at one institution

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