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J Nucl Med. 2019 Mar 8. pii: jnumed.118.224543. doi: 10.2967/jnumed.118.224543. [Epub ahead of print]

Intention to treat analysis of 68Ga-PSMA and 11C-choline PET/CT versus CT for prostate cancer recurrences after surgery.

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Eberhard Karls University Tübingen, Germany.
Werner Siemens Imaging Center, Department of Preclinical Imaging and Radiopharmacy, Germany.


Biochemical recurrence (BCR) after prostate cancer surgery is very common, even after additional salvage radiotherapy (SRT). This might be explained by target miss. Improved diagnostic accuracy provided by PET could potentially circumvent this therapeutic gap. Therefore, we evaluated consecutive 68Ga-PSMA-, 11C-choline PET/CT and standard CT imaging in the same patient with regard to TNM-stage migration and accordingly adapted curative radiotherapy (RT) options including ablative treatment of oligometastases (n≤5). Cost efficacy of PET- versus CT-based treatment is also calculated. The prospective register database (064/2013BO1) was retrospectively searched for patients fulfilling the following inclusion criteria: 1. BCR after radical prostatectomy (pT2-4 pN0-1 cM0, postoperative RT allowed). 2. 11C-choline, 68Ga-PSMA-PET/CT and diagnostic CT performed within the same day. 3. Available clinical data. Ten treatment routines were defined according to current practice. Furthermore, intention to treat and treatment-related costs depending on stage shift of TNM-staging after imaging were analyzed. Eighty-three patients were eligible (median PSA-level 1.9 ng/ml). Both PET-examinations led to concordant results in 72% of patients, while concordance of TNM-staging between 68Ga-PSMA-PET and diagnostic CT was only 36%. Incorrect staging would lead to "wrong" treatment and therefore to additional costs. A 68Ga-PSMA-PET would be cost-effective if additional costs do not exceed 3,843 € (vs. CT). The number needed to image (NNI) was 2 (for CT) and 4 (for 11C-choline-PET) to avoid one incorrect treatment. In addition, 68Ga-PSMA-PET-staging enabled new curative options in half of the patients with previous RT who otherwise receive palliative ADT. 68Ga-PSMA PET/CT is cost-effective with regard to avoided incorrect treatment for all patients. It enabled new curative options for patients with previous RT who are usually treated palliatively. Therefore, PSMA-PET/CT staging should become standard for BCR after surgery±RT.


68Ga-PSMA-PET/CT; Oncology: GU; PET/CT; Radiation Therapy Planning; SBRT; oligometastasis; prostate cancer


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