Theranostics in nuclear oncology combines diagnostic and therapeutic procedures using radiotracers to target tumor cells. Prostate-specific membrane antigen (PSMA) is a key target in metastatic prostate cancer, and the radioligand [177Lu]Lu-PSMA-617, which binds to PSMA, has shown promising results in treating metastatic castration-resistant prostate cancer (mCRPC), leading to its approval by the European Medicines Agency in 2022. In this narrative review, the current evidence of [177Lu]Lu-PSMA-617 in mCRPC was discussed in the context of selected studies and the joint EANM/SNMMI guidelines for Lutetium-177-labeled PSMA-targeted radioligand therapy. The use of [177Lu]Lu-PSMA-617 for post-chemotherapy mCRPC is supported by substantial evidence from the phase II TheraP and the phase III VISION trials, demonstrating its safety and efficacy. The theranostic approach identifies patients likely to benefit from [177Lu]Lu-PSMA-617, which is effective only in tumors with sufficient PSMA expression, as detected by PSMA-ligand PET/CT, which is also used for response assessment. The success of [177Lu]Lu-PSMA-617 in post-chemotherapy mCRPC patients has led to further ongoing studies evaluating its use earlier in the treatment sequence, prior to chemotherapy. To ensure beneficial treatment outcome, adequate patient selection and evaluation of imaging-based response through PSMA-ligand PET/CT is necessary.

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I (MP37)1 May 2024MP37-19 SIZE OF LYMPH-NODE METASTASES IN PROSTATE CANCER PATIENTS UNDERGOING RADICAL PROSTATECTOMY: IMPLICATION FOR IMAGING AND ONCOLOGIC FOLLOW-UP OF 2705 LYMPH-NODE POSITIVE PATIENTS Fabian Falkenbach, Mykyta Kachanov, Sami-Ramzi Leyh-Bannurah, Tobias Maurer, Sophie Knipper, Daniel Köhler, Markus Graefen, Guido Sauter, and Lars Budäus Fabian FalkenbachFabian Falkenbach , Mykyta KachanovMykyta Kachanov , Sami-Ramzi Leyh-BannurahSami-Ramzi Leyh-Bannurah , Tobias MaurerTobias Maurer , Sophie KnipperSophie Knipper , Daniel KöhlerDaniel Köhler , Markus GraefenMarkus Graefen , Guido SauterGuido Sauter , and Lars BudäusLars Budäus View All Author Informationhttps://doi.org/10.1097/01.JU.0001008948.02935.01.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Despite modern imaging modalities, the visibility of lymph-node metastases (LNMs) is critically influenced by their size. Aim of the study was to assess the distribution of maximal tumor diameters (i.e., size) in LNMs of pN1-PCa at RP and its impact on visibility in preoperative imaging and oncological outcomes. METHODS: Overall, 2705 consecutive patients with pN1-PCa at RP, harboring a cumulative 7510 LNMs, were analyzed. Descriptive and multivariable analyses addressed the risk of micrometastases (MM)-only disease and the visibility of LNMs. Kaplan-Meier curves and Cox analyses were used for biochemical recurrence-free survival (BCRFS) stratified for MM-only disease. RESULTS: The median LNM size was 4.5 mm (IQR: 2.0-9.0 mm). Of 7510 LNMs, 1966 (26%) were MM (≤2 mm). On preoperative imaging, 526 patients (19%) showed suspicious findings (PSMA-PET/CT: 169/344, 49%). In multivariable analysis, prostate-specific antigen (OR 0.98), age (OR 1.01), a Gleason score >7 at biopsy (OR 0.73), percentage of positive cores at biopsy (OR 0.36), and neoadjuvant treatment (OR 0.51) emerged as independent predictors for less MM-only disease (p<0.05). Patients with MM-only disease compared to those harboring larger LNMs had a longer BCRFS (median 60 versus 29 months, p<0.0001) (Figure 1). CONCLUSIONS: Overall, 26% of LNMs were MM (≤2 mm). Adverse clinical parameters were inversely associated with MM at RP. Consequently, PSMA-PET/CT did not detect a substantial proportion of LNMs and surgical staging remains important in such patients. LNM size impacts oncological prognosis. Download PPT Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e610 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Fabian Falkenbach More articles by this author Mykyta Kachanov More articles by this author Sami-Ramzi Leyh-Bannurah More articles by this author Tobias Maurer More articles by this author Sophie Knipper More articles by this author Daniel Köhler More articles by this author Markus Graefen More articles by this author Guido Sauter More articles by this author Lars Budäus More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyProstate Cancer: Detection & Screening IV (MP49)1 May 2024MP49-11 PSA-DENSITY, DRE, AND PI-RADS 5: POTENTIAL SURROGATES FOR OMITTING PROSTATE BIOPSY? Fabian Falkenbach, Francesca Ambrosini, Mykyta Kachanov, Gernot Ortner, Tobias Maurer, Daniel Köhler, Dirk Beyersdorff, Markus Graefen, and Lars Budäus Fabian FalkenbachFabian Falkenbach , Francesca AmbrosiniFrancesca Ambrosini , Mykyta KachanovMykyta Kachanov , Gernot OrtnerGernot Ortner , Tobias MaurerTobias Maurer , Daniel KöhlerDaniel Köhler , Dirk BeyersdorffDirk Beyersdorff , Markus GraefenMarkus Graefen , and Lars BudäusLars Budäus View All Author Informationhttps://doi.org/10.1097/01.JU.0001008696.31772.28.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In contrast to other malignancies, histologic confirmation of prostate cancer (PCA) prior to treatment is common in patients with a high suspicion of clinically significant PCA (csPCA). To analyze the impact of extracapsular extension (ECE), cT-stage defined by digital rectal examination (DRE), and PSA-density (PSA-D) on detection of csPCA in patients with at least one PI-RADS 5 lesion (hereinafter, "PI-RADS 5 patients"). METHODS: PI-RADS 5 patients (pt.) who underwent MRI/Ultrasound fusion biopsy (Bx) between 2016 and 2020 were identified in our institutional database. Uni- and multivariable logistic-regression models were used to identify predictors of csPCA-detection (GGG≥2). Risk models were adjusted for ECE, PSA-D, and cT-stage. Corresponding Receiver Operating Characteristic (ROC) curves and areas under the curve (AUC) were calculated. RESULTS: Among 493 consecutive PI-RADS 5 patients, the median age and PSA was 69 years (interquartile range [IQR]: 63–74) and 8.9 ng/ml (IQR: 6.0–13.7), respectively. CsPCA was detected in 405/493 pt. (82%); 36/493 pt. (7%) had no cancer. When tabulating for PSA-D of>0.2 ng/ml/cc and>0.5 ng/ml/cc, csPCA was found in 228/253 pt. (90%, PI-RADS5+PSA-D >0.2 ng/ml/cc) and 54/54 pt. (100%, PI-RADS5+PSA-D >0.5 ng/ml/cc). Finally, a model incorporating PSA-D and cT-stage achieved an AUC of 0.79 (95% Confidence Interval: 0.74-0.83). CONCLUSIONS: In PI-RADS 5 patients, PSA-D and cT-stage emerged as strong co-predictors of csPCA at biopsy. Moreover, when adding the threshold of PSA-D >0,5 ng/ml/cc, all PI-RADS 5 patients were diagnosed with csPCA. Therefore, straight treatment for PCA can be considered, especially if risk factors for biopsy-related complications such as obligatory dual platelet inhibition are present. Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e787 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Fabian Falkenbach More articles by this author Francesca Ambrosini More articles by this author Mykyta Kachanov More articles by this author Gernot Ortner More articles by this author Tobias Maurer More articles by this author Daniel Köhler More articles by this author Dirk Beyersdorff More articles by this author Markus Graefen More articles by this author Lars Budäus More articles by this author Expand All Advertisement PDF downloadLoading ...

Pulmonary embolism is a potentially fatal condition with increased mortality if anticoagulation is delayed. This study aimed to find influencing factors on the duration from requesting a computed tomography (CT) pulmonary angiography (CTPA) to performing a CTPA in suspected acute pulmonary embolism. In 1849 cases, automatically generated time data were extracted from the radiological information system. The impact of the distance to the scanner, case-related features (sector of patient care, triage), and workload (demand for CTs, performed CTs, available staff, hospital occupancy) were investigated retrospectively using multiple regression. The time to CTPA was shorter in cases from the emergency room (ER) than in inpatients and outpatients at distances below 160 m and 240 m, respectively. While requests from the ER were also performed faster than cases from regular wards (< 180 m), no difference was found between the ER and intensive care units. Compared to “not urgent” cases, the workflow was shorter in “urgent” (− 17%) and “life-threatening” (− 67%) situations. The process was prolonged with increasing demand (+ 5%/10 CTs). The presented analysis identified relevant in-hospital influences on the CTPA workflow, including the distance to the CT together with the sector of patient care, the case triage, and the demand for imaging.

Background and objective: In patients with oligorecurrent prostate cancer (PCa), prostate-specific membrane antigen-targeted radioguided surgery (PSMA-RGS) prolongs treatment-free survival. Data on patient-reported outcome measures (PROMs) are lacking. Methods: A retrospective assessment of validated PROMs (12-item Short Form Health Survey [SF-12], 26-item Expanded Prostate Index Composite, and Decision Regret Scale [DRS]) was performed before and after PSMA-RGS for oligorecurrent PCa. Mixed models were used. Key findings and limitations: A total of 373 patients were analyzed at a median (interquartile range [IQR]) age of 66 (61, 70) yr and prostate-specific antigen of 0.8 (0.4, 1.5) ng/ml. Six months after PSMA-RGS, the median (IQR) scores for the PROMs were as follows: SF-12 physical 54 (49, 56), SF-12 mental 53 (43, 56), urinary incontinence 86 (52, 100), urinary irritation 94 (88, 100), sexual 27 (9, 57), hormonal 90 (79, 100), and bowel 96 (83, 100). Only the sexual score decreased in a significant fashion from baseline over time (median [IQR], 17 [8,38]) after 3 yr vs 37 [13, 63] at baseline, p = 0.01). The decision regret remained low (median [IQR] DRS at 1 yr: 5 [0, 20]). More than 90% of the patients reported that PSMARGS was the correct decision after 1 yr. Conclusions and clinical Implications: We recorded no significant decrease in quality of life or any functional status domain, except sexual. While decision regret was low, sexual functioning might deteriorate further.

Objectives: To compare the feasibility and reliability of manual versus software-assisted assessments of computed tomography scans according to iRECIST in patients undergoing immune-based cancer treatment. Methods: Computed tomography scans of 30 tumor patients undergoing cancer treatment were evaluated by four independent radiologists at baseline (BL) and two follow-ups (FU), resulting in a total of 360 tumor assessments (120 each at BL/FU1/FU2). After image interpretation, tumor burden and response status were either calculated manually or semi-automatically as defined by software, respectively. The reading time, calculated sum of longest diameter (SLD), and tumor response (e.g., “iStable Disease”) were determined for each assessment. After complete data collection, a consensus reading among the four readers was performed to establish a reference standard for the correct response assignments. The reading times, error rates, and inter-reader agreement on SLDs were statistically compared between the manual versus software-assisted approaches. Results: The reading time was significantly longer for the manual versus software-assisted assessments at both follow-ups (median [interquartile range] FU1: 4.00 min [2.17 min] vs. 2.50 min [1.00 min]; FU2: 3.75 min [1.88 min] vs. 2.00 min [1.50 min]; both p < 0.001). Regarding reliability, 2.5% of all the response assessments were incorrect at FU1 (3.3% manual; 0% software-assisted), which increased to 5.8% at FU2 (10% manual; 1.7% software-assisted), demonstrating higher error rates for manual readings. Quantitative SLD inter-reader agreement was inferior for the manual compared to the software-assisted assessments at both FUs (FU1: ICC = 0.91 vs. 0.93; FU2: ICC = 0.75 vs. 0.86). Conclusions: Software-assisted assessments may facilitate the iRECIST response evaluation of cancer patients in clinical routine by decreasing the reading time and reducing response misclassifications.

Background In a subset of patients with oligorecurrent prostate cancer (PCa), salvage surgery with prostate-specific membrane antigen (PSMA) radioguided surgery (PSMA-RGS) seems to be of value. Objective To evaluate whether a lower level of postoperative prostate-specific antigen (PSA; <0.1 ng/ml) is predictive of therapy-free survival (TFS) following salvage PSMA-RGS. Design, setting, and participants This cohort study evaluated patients with biochemical recurrence after radical prostatectomy and oligorecurrent PCa on PSMA positron emission tomography treated with PSMA-RGS in three tertiary care centers (2014–2022). Intervention PSMA-RGS. Outcome measurements and statistical analysis Postsalvage surgery PSA response was categorized as <0.1, 0.1–<0.2, or >0.2 ng/ml. Kaplan-Meier and multivariable Cox regression models evaluated TFS according to PSA response. Results and limitations Among 553 patients assessed, 522 (94%) had metastatic soft tissue lesions removed during PSMA-RGS. At 2–16 wk after PSMA-RGS, 192, 62, and 190 patients achieved PSA levels of <0.1, 0.1–<0.2, and >0.2 ng/ml, respectively. At 2 yr of follow-up, TFS rate was 81.1% versus 56.1% versus 43.1% (p < 0.001) for patients with PSA <0.1 versus 0.1–<0.2 versus >0.2 ng/ml. In multivariable analyses, PSA levels of 0.1–0.2 ng/ml (hazard ratio [HR]: 1.9, confidence interval [CI]: 1.1–3.1) and ≥0.2 ng/ml (HR: 3.2, CI: 2.2–4.6, p < 0.001) independently predicted the need for additional therapy after PSMA-RGS. The main limitation is the lack of a control group. Conclusions For patients after salvage PSMA-RGS, a lower biochemical response (PSA <0.1 ng/ml) seems to predict longer TFS. This insight may help in counseling patients postoperatively as well as guiding the timely selection of additional therapy. Patient summary We studied what happened to prostate cancer patients in three European centers who had salvage surgery using a special method called prostate-specific membrane antigen–targeted radioguidance. We found that patients who had low prostate-specific antigen levels soon after surgery were less likely to need further treatment for a longer time.

BACKGROUND:To evaluate how prostate-specific antigen (PSA) levels decrease after removal of isolated prostate cancer (PCa) nodal metastases in relation to their diameter/volume ("PSA-density of PCa-metastases") and maximum standardized uptake value (SUVmax). METHODS:A total of 83 consecutive patients with solitary nodal recurrence after radical prostatectomy who underwent prostate-specific membrane antigen-radioguided salvage surgery were retrospectively analyzed. Using multivariable linear regression models, the PSA-decrease after removal of each PCa-metastases (=PSA-contribution of each PCa-metastases) was correlated with the long axis diameter/estimated volume and the SUVmax of each removed metastasis. Sizes were measured by imaging and histopathologic examination. RESULTS:A total of 83 patients were included with a median (interquartile range [IQR]) PSA-decrease of 0.56 [0.22, 1.31] ng/mL after salvage surgery. The median [IQR] long axis diameters in imaging and histopathological examination were 8.0 [6.0, 11.0] mm and 8.4 [5.5, 11.1] mm, respectively. The median [IQR] estimated volumes were 0.13 [0.05, 0.32] cc (imaging) and 0.05 [0.02, 0.17] cc (pathology). In multivariable linear regression analyses, the estimated PSA-contribution ([95% confidence interval [CI]) of each millimeter of long axis diameter was 0.09 [0.03, 0.14] ng/mL (imaging) or 0.08 [0.03, 0.12] ng/mL (histology). The minimum diameter for biochemical recurrence (PSA ≥ 0.2 ng/mL) was >2.2 mm (imaging) or >2.5 mm (histology). The estimated PSA-contribution [95% CI] of each cc cancer volume was 1.23 [0.51, 1.94] ng/mL (imaging) or 1.46 [0.40, 2.52] ng/mL (histology). SUVmax as surrogate parameter for tissue composition was associated with increased PSA-contribution of PCa-metastases (+0.03-0.05 ng/mL per unit increase). CONCLUSIONS:The diameter/volume and SUVmax of metastatic tissue correlate with its contribution to PSA levels. Therefore, very small metastases may produce too little PSA for biochemical recurrence.

We evaluated the prognostic role of pre-salvage prostate-specific membrane antigen–radioguided surgery (PSMA-RGS) serum levels of alkaline phosphatase (AP), carcinoembryonic antigen (CEA), lactate dehydrogenase (LDH), and neuron-specific enolase (NSE). Patients who consecutively underwent PSMA-RGS for prostate cancer (PCa) oligorecurrence between January 2019 and January 2022 were selected. Biomarkers were assessed one day before surgery. Cox regression and logistic regression models tested the relationship between biochemical recurrence-free survival (BFS), 6- and 12-month biochemical recurrence (BCR), and several independent variables, including biomarkers. 153 consecutive patients were analyzed. In the univariable Cox regression analysis, none of the biomarkers achieved predictor status (AP: hazard ratio [HR] = 1.03, 95

Objectives Infections are common complications in venous access ports. The presented analysis aimed to investigate the incidence, microbiological spectrum, and acquired resistances of pathogens in upper arm port associated infections to provide a decision aid in the choice of therapy. Materials and methods In total, 2667 implantations and 608 explantations were performed at a high-volume tertiary medical center between 2015 and 2019. In cases with infectious complications (n = 131, 4.9%), procedural conditions and results of microbiological testing were reviewed retrospectively. Results Of 131 port associated infections (median dwell time 103 days, interquartile range 41–260), 49 (37.4%) were port pocket infections (PPI) and 82 (62.6%) were catheter infections (CI). Infectious complications occurred more often after implantation in inpatients compared to outpatients (P < 0.01). PPI were mainly caused by Staphylococcus aureus (S. aureus, 48.3%) and coagulase-negative staphylococci (CoNS, 31.0%). Other gram-positive and gram-negative species were encountered in 13.8% and 6.9%, respectively. CI were caused less frequently by S. aureus (8.6%) than CoNS (39.7%). Other gram-positive and gram-negative strains were isolated in 8.6% and 31.0%, respectively. Candida species were seen in 12.1% of CI. An acquired antibiotic resistance was detected in 36.0% of all significant isolates, occurring especially in CoNS (68.3%) and gram-negative species (24.0%). Conclusions Staphylococci comprised the largest group of pathogens in upper arm port associated infections. However, gram-negative strains and Candida species should also be considered as a cause of infection in CI. Due to the frequent detection of potential biofilm-forming pathogens, port explantation is an important therapeutic measure, especially in severely ill patients. Acquired resistances must be anticipated when choosing an empiric antibiotic treatment.

To compare the oncological and surgical outcomes of patients with recurrent prostate cancer (PCa) who underwent either open or newly established robot-assisted salvage prostate-specific membrane antigen–radioguided surgery (PSMA-RGS). Patients who consecutively underwent PSMA-RGS for PCa recurrence between January 2021 and December 2022 were identified. The rate of complete biochemical response, biochemical recurrence-free survival [BFS], and the rate of salvage therapy were evaluated. Univariable and multivariable regression models tested the association between the surgical approach and surgical outcomes. Overall, 85 patients were selected, with 61 patients (72

Prostate-specific membrane antigen-PET has become a valuable diagnostic tool. The second version of the Prostate Cancer Molecular Imaging Standardized Evaluation framework is the next step towards a standardized evaluation and reporting system from primary staging to reassessment of advanced prostate cancer.

We present the case of a patient who underwent an open radical prostatectomy with pelvic lymph node dissection (Gleason 4+3, pT3a pN1 R0) in March 2017. In November 2020, prostate-specific membrane antigen (PSMA)-radioguided salvage lymph node dissection was planned due to a single left para-rectal lymph node at a [68Ga] Ga-PSMA-I&T PET. In January 2022, the [68Ga] Ga-PSMA-I&T PET showed an isolated liver lesion. Biopsy confirmed prostate adenocarcinoma. A liver segmentectomy was performed. A complete biochemical response was reported until the last follow-up (December 2022). Prostate-specific membrane antigen positron emission tomography (PSMA PET)-directed metastasis-directed therapy may be an effective treatment in selected cases, allowing a benefit in the oncological outcome.

PURPOSE:To identify reasons for negative histopathology of specimens from prostate-specific membrane antigen (PSMA) radioguided surgery (PSMA-RGS) in recurrent prostate cancer (PCa) after prostatectomy. METHODS:Of 302 patients who underwent PSMA-RGS, 17 (5.6%) demonstrated a negative histopathology. Preoperative data, PSMA PET, PSMA SPECT, and follow-up information were analyzed retrospectively to differentiate true/false positive (TP/FP) from true/false negative (TN/FN) lesions. RESULTS:The median prostate-specific antigen at PET was 0.4 ng/ml (interquartile range [IQR] 0.3-1.2). Twenty-five index lesions (median short axis 7 mm, IQR 5-8; median long-axis 12 mm, IQR 8-17) had a median SUVmax of 4 (IQR 2.6-6; median PSMA expression score 1, IQR 1-1). Six lesions were TP, twelve were FP, one was TN, and six remained unclear. All TP lesions were in the prostatic fossa or adjacent to the internal iliac arteries. Three suspected local recurrences were FP. All FP lymph nodes were located at the distal external iliac arteries or outside the pelvis. A low PSMA-expressing TN node was identified next to a common iliac artery. Unclear lesions were located next to the external iliac arteries or outside the pelvis. CONCLUSION:In most cases with a negative histopathology from PSMA-RGS, lesions were FP on PSMA PET. Unspecific uptake should be considered in low PSMA-expressing lymph nodes at the distal external iliac arteries or outside the pelvis, especially if no PSMA-positive lymph nodes closer to the prostatic fossa are evident. Rarely, true positive metastases were missed by surgery or histopathology.

BACKGROUND AND OBJECTIVE:Metastasis-directed therapy is a feasible option for low PSA, recurrent locoregional metastatic prostate cancer. After initial salvage surgery, patients with good response might consider a repeat salvage surgery in case of recurrent, isolated, and PSMA-positive metastases. This analysis aimed to evaluate the oncological outcome and safety of repeat PSMA-targeted radioguided surgery (RGS) after either prior RGS or "standard" salvage lymph node dissection (SLND). MATERIALS AND METHODS:We identified 37 patients undergoing repeat RGS after prior SLND (n = 21) (SLND-RGS) or prior RGS (n = 16) (RGS-RGS) between 2014 and 2021 after initial radical prostatectomy with or without pelvic radiation therapy at two German tertiary referral centers. Kaplan-Meier analyses and uni-/multivariable Cox regression models were used to investigate factors associated with biochemical recurrence-free survival (BRFS) and treatment-free survival (TFS) after repeat salvage surgery. RESULTS AND LIMITATIONS:Complete Biochemical Response (cBR, PSA < 0.2 ng/ml) was observed in 20/32 patients (5 NA). Median overall BRFS [95% confidence interval (CI)] after repeat salvage surgery was 10.8 months (mo) (5.3-22). On multivariable regression, only age (HR 1.09, 95% CI 1.01-1.17) and preoperative PSA (HR 1.23, 95% CI 1.01-1.50) were associated with shorter BRFS, although PSA (HR 1.16, 95% CI 0.99-1.36) did not achieve significant predictor status in univariable analysis before (p value = 0.07). Overall, one year after second salvage surgery, 89% of the patients (number at risk: 19) did not receive additional treatment and median TFS was not reached. Clavien-Dindo grade > 3a complications were observed in 8% (3/37 patients). Limitations are the retrospective evaluation, heterogeneous SLND procedures, lack of long-term follow-up data, and small cohort size. CONCLUSION:In this study, repeat RGS was safe and provided clinically meaningful biochemical recurrence- and treatment-free intervals for selected cases. Patients having low preoperative PSA seemed to benefit most of repeat RGS, irrespective of prior SLND or RGS or the time from initial RP/first salvage surgery.

This case series evaluated the feasibility of prostate-specific membrane antigen (PSMA)-radioguided surgery (RGS) with Tc-99m-MIP-1404 in recurrent prostate cancer. Methods: Nine patients with PSMA-positive lesions on PET/CT received 99mTc-MIP-1404 (median, 747 MBq; interquartile range [IQR], 710-764 MBq) 17.2 h (IQR, 16.9-17.5 h) before SPECT/CT and 22.3 h (IQR, 20.8-24.0 h) before RGS. Results: Seventeen PSMA-positive lesions were detected on PET/CT (median short-axis diameter, 4 mm; IQR, 3-6 mm; median SUVmax, 8.9; IQR, 5.2-12.6). Nine of 17 (52.9%) were visible on SPECT/CT (median SUVmax, 13.8; IQR, 8.0-17.9). Except for 2 foci, all PET/CT-positive findings demonstrated intraoperative count rates above the background level (median count, 31; IQR, 17-89) and were lymph node metastases. Moreover, PSMA-RGS identified 2 additional metastases compared with PET/CT. Prostate-specific antigen values decreased after RGS in 6 of 9 patients (67%). Conclusion: PSMA-RGS with Tc-99m-MIP-1404 identified lymph node metastases in all patients, including 2 additional lesions compared with PET/CT.

Objective: To assess the influence of biochemical recurrence (BCR) risk groups and PSA kinetics on the outcomes of radioguided surgery against prostate-specific membrane antigen (PSMA-RGS). Currently, neither BCR risk group nor PSA doubling time (PSA-DT), or PSA velocity (PSA-V) are actively assigned or relevant for counseling prior to PSMA-RGS. Methods: We retrospectively analyzed PSMA-RGS cases for oligorecurrent prostate cancer between 2014 and 2023. BCR risk groups, PSA-DT, and PSA-V were analyzed as predictors for complete biochemical response (cBR, PSA < 0.2 ng/mL), BCR-free, and therapy-free survival (BCRFS, TFS). Results: Of 374 included patients, only 21/374 (6%) and 201/374 (54%) were classified as low- and high-risk BCR (no group assignment possible in 152/374, 41%). A total of 13/21 (62%) patients with low- and 120/201 (60%) with high-risk BCR achieved cBR (p = 1.0). BCR classification was no predictor for BCRFS (HR:1.61, CI: 0.70–3.71, p = 0.3) or subsequent TFS (HR:1.07, CI: 0.46–2.47, p = 0.9). A total of 47/76 (62%) patients with PSA-DT ≤ 6 mo and 50/84 (60%) with PSA-DT > 6 mo achieved cBR (p = 0.4). PSA-DT was not associated with cBR (OR: 0.99, CI: 0.95–1.03, p = 0.5), BCRFS (HR: 1.00, CI: 0.97–1.03, p = 0.9), or TFS (HR: 1.02, CI: 0.99–1.04, p = 0.2). Consistent negative findings were recorded for PSA-V. Conclusions: The BCR risk groups and PSA kinetics do not predict the oncological success of PSMA-RGS performed at low absolute PSA values. Indolent low-risk BCR is rarely treated by PSMA-RGS.

BACKGROUND:Defining the best surgical template for salvage lymph node dissection (SLND) in patients exhibiting unilateral prostate cancer (PCa) recurrence in pelvic lymph nodes (LNs) is an unmet need. We assessed the risk of missing contralateral nodal recurrence in patients with unilateral positive PSMA-PET who were treated with bilateral PSMA-radioguided (RGS) SLND.METHODS:Patients who consecutively underwent bilateral PSMA-radioguided SLND for PCa recurrence between April 2014 and January 2023 were identified. We compared PSMA PET findings with the number and the location of PCa LN metastases of the final pathological report. Univariable logistic regression models to try to predict contralateral missed disease were performed.RESULTS:Sixty patients were identified. At PSMA-RGS, the median PSA level was 0.71 ng/mL (IQR: 0.38-2.28). At PSMA-PET pre-SLND, 49 (82%) patients had unilateral exclusively pelvic lesions, 2 (3%) had unilateral positive nodes at the level of the common iliac arteries, and 9 (15%) had unilateral positive nodes in both levels. Final pathology revealed unilateral LN involvement in 43 (72%), a negative report in 3 (5%), and bilateral positive lesions in 14 (23%) patients. In the univariable logistic regression models, none of the tested factors showed influence on missing contralateral lesions. Four patients out of 35 (11%) with one positive LN at PSMA-PET had bilateral PCa recurrence.CONCLUSIONS:Patients with one-sided positive LNs on PSMA PET can be considered for a unilateral PSMA-radioguided SLND template with the caveat that about a quarter of patients ultimately have bilateral positive LNs. Larger prospective randomized trials are needed to confirm our findings.

In this prospective two-center feasibility study, we evaluate the diagnostic value of intraoperative ex vivo specimenPET/CT imaging of radical prostatectomy (RP) and lymphadenectomy specimens. Ten patients with high-risk prostate cancer under-went clinical prostate-specific membrane antigen (PSMA) positron emission tomog-raphy/computed tomography (PET/CT) preoperatively on the day of surgery. Six patients received Ga-68-PSMA-11 and four F-18-PSMA-1007. Radioactivity of the resected specimen was measured again using a novel specimenPET/CT device (AURA10; XEOS Medical, Gent, Belgium) developed for intraoperative margin assessment. All index lesions of staging multiparametric magnetic resonance imaging could be visualized. Overall, specimenPET/CT correlated well with conventional PET/CT regarding detection of suspicious tracer foci (Pearson coefficient 0.935). In addition, specimenPET/CT demonstrated all lymph node metastases detected on conventional PET/CT (n = 3), as well as three previously undetected lymph node metastases. Importantly, all positive or close (<1 mm) surgical margins could be visualized in agreement with histopathology. In conclusion, specimenPET/CT enables detection of PSMA-avid lesions and warrants further investigation to tailor RP, based on a good correlation with final pathology. Future trials will prospectively compare ex vivo specimenPET/CT with a frozen section analysis for the detection of positive surgical margins and assessment of biochemical recurrence-free survival. Patient summary: In this report, we examined prostatectomy and lymphadenectomy specimens for suspicious positron emission tomography (PET) signals after preoperative tracer injection. It was found that in all cases, a good signal could be visualized, with a promising correlation of surface assessment compared with histopathology. We conclude that specimenPET imaging is feasible and may help improve oncological outcomes in the future. (c) 2023 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creative-commons.org/licenses/by-nc-nd/4.0/).

Background Prostate cancer (PCa) is the most common malignancy in men and the second most common tumor-associated cause of death in the male population in Germany. Prostate-specific membrane antigen (PSMA)-targeted hybrid imaging using positron emission tomography (PET) in combination with CT or MRI represents a comparably new method that gained increasing importance in the diagnostic process of PCa in recent years. Method Current applications of PSMA hybrid imaging were summarized according to the German and European guidelines on PCa. New developments were elaborated based on a literature review of PubMed conducted in 10/22. Results PSMA-PET/CT demonstrated higher detection rates for metastases in high-risk PCa and recurrent PCa after primary therapy than established imaging methods (CT, MRI, and bone scan). Despite promising results from prospective trials in both scenarios and substantial influence on clinical decision making, data regarding the influence of PSMA-PET on PCa-specific and overall survival are still lacking. Hence, PSMA PET/CT is recommended with a "weak" strength rating in most situations. However, its importance in new treatment options like metastasis-directed therapy or PSMA-radioligand therapy expands the scope of PSMA-PET in the clinical routine. Conclusion PSMA-targeting hybrid imaging represents the most sensitive diagnostic test in several stages of PCa and allows the development of new treatment strategies. Prospective studies are needed to evaluate the influence of PSMA-PET on patient survival.