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Prebiopsy 68Ga-PSMA PET imaging: can we improve the current diagnostic pathway for prostate cancer?

Prostate Cancer and Prostatic Diseases volume 26, pages 47–49 (2023)Cite this article

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Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) is rapidly expanding in the diagnostic pathway of prostate cancer (PCa). 68Ga-PSMA PET/CT, the most studied PSMA radiotracer, is currently recommended in case of biochemical recurrence after radical prostatectomy [1]. It is also being progressively used before surgery [2] for primary staging of high-risk prostate cancer, particularly when conventional imaging is negative with high clinical suspicion of metastatic disease. The use of 68Ga-PSMA PET/CT for initial prostate cancer diagnosis, before biopsy, is however more debatable. Indeed, multiparametric MRI (mpMRI) is already a well-established and highly accurate imaging modality for the primary staging and assessment of local tumor status. The PROMIS [3] and PRECISION [4] trials have demonstrated that mpMRI has a high sensitivity (>90%) and an excellent negative predictive value for clinically significant disease; yet, real life data is not as promising, as MRI interpretation is highly dependent on the radiologists’ experience and quality of images [5]. Moreover, a recent review of over 1500 patients demonstrated that the risk of developing clinically significant prostate cancer (csPCa) 2 years after a negative mpMRI was of only 5% in biopsy-naïve patients, and 4% in prior-biopsy negative patients [6]. In other terms, most csPCa will be detected by clinical follow-up, mpMRI or repeated biopsy. Even in the absence of mpMRI (or as an alternative), tissue-based testing (Oncotype Dx®, Prolaris®, Decipher®, and ProMark®) can be used to improve clinical decision making in localized disease [7].

Therefore, when discussing the potential role of 68Ga-PSMA PET/CT or 68Ga-PSMA PET/MRI in the pre-biopsy setting, one must keep in mind that the comparator is mpMRI, a diagnostic imaging with an already demonstrated clinical meaningfulness. However, we know that PCa contains a wide spectrum of diseases, with a vast heterogeneity in terms of biologic behavior, aggressiveness and response to therapy. Certainly, various forms of disease will be more easily detected with on technique or another, yet to date no valid biomarker exists to define which type of cancer can be optimally visualized and evaluated with one imaging technique or another. Herein, we will review the potential benefits of implementing 68Ga-PSMA PET-based imaging (PET/CT or PET/MRI) in the prebiopsy setting and what are the consequences of performing this exam before prostatic biopsy.

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Data availability

The data that support the findings of this study are available in the mansucripts cited in the Reference section.

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Authors and Affiliations

  1. Department of Urology, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium

    Simone Albisinni, Julien Sarkis & Romain Diamand

  2. Department of Urology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium

    Simone Albisinni & Romain Diamand

  3. Urology Unit, Department of Surgical Sciences, Tor Vergata University Hospital, University of Rome Tor Vergata, Rome, Italy

    Simone Albisinni

  4. Department of Urology, Ospedale Sant’Andrea, Sapienza University, Roma, Italy

    Cosimo De Nunzio

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Manuscript conceptualization: SA, CDN, Manuscript drafting: SA, JS, RD. Supervision: CDN.

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Correspondence to Simone Albisinni.

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Albisinni, S., Sarkis, J., Diamand, R. et al. Prebiopsy 68Ga-PSMA PET imaging: can we improve the current diagnostic pathway for prostate cancer?. Prostate Cancer Prostatic Dis 26, 47–49 (2023). https://doi.org/10.1038/s41391-022-00593-8

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