Oligometastatic disease in biochemical recurrence of prostate cancer: Prevalence on PSMA PET/CT and consecutive metastasis-directed therapy – Experience at a tertiary referral center

Abstract

Aim The aim of our study was to address the prevalence of oligometastatic recurrent prostate cancer (PCa) on PSMA-PET and the associated practice of metastasis-directed therapy (MDT). Next, we aimed to determine a PSA threshold below which most patients had local and/or oligometastatic recurrence on PSMA-PET.

Methods One hundred and ten consecutive patients with biochemical recurrence (BCR) after radical prostatectomy (RP) ± radiation were referred for ⁶⁸Ga-PSMA-11 or ¹⁸F-DCFPyL PET/CT. We correlated the location and number of PSMA-positive lesions against the treatment choice after imaging. Detection rates were stratified by PSA levels at the time of PET/CT. The study design was monocentric retrospective.

Results Thirty-four patients (30.9%) had a PSMA-negative scan, while 17 (15.5%) had local recurrence and 59 (53.6%) had metastatic recurrence on PSMA-PET. ROC analysis revealed a cut-off of ≤3 metastatic lesions on PSMA-PET for the steering of treatment decisions towards MDT rather than solely systemic therapy (AUC: 0.88). Defined as 3 or fewer metastatic lesions, oligometastatic recurrent PCa was found in up to 30% (33/110) of all patients. At PSA levels below 3.5 ng/ml, the rate of PSMA-positive disease that was locally confined or oligometastatic was 76% (45/59), dropping significantly to 29.4% (5/17) above this threshold (p<0.001) as polymetastatic findings became more frequent.

Conclusion The detection of ≤3 oligometastases on PSMA-PET encouraged the consecutive pursuit of MDT instead of systemic therapy alone. PSMA-PET predominantly captured patients at recurrence stages amenable to localized treatment when initiated at PSA levels below 3.5 ng/ml.

Zusammenfassung

Ziel Ziel unserer Studie war es, die Prävalenz des oligometastatisch rezidivierten Prostatakarzinoms (PCa) in der PSMA-PET sowie die damit verbundene Praxis der Metastasen-gerichteten Therapie (MDT) zu untersuchen. Anschließend sollte ein PSA-Schwellenwert ermittelt werden, unterhalb dem die Patienten in der Regel ein lokales und/oder oligometastatisches Rezidiv in der PSMA-PET aufwiesen.

Methoden 110 konsekutive Patienten mit biochemischem Rezidiv (BCR) nach radikaler Prostatektomie (RP) ± Bestrahlung wurden zur ⁶⁸Ga-PSMA-11 oder ¹⁸F-DCFPyL-PET/CT überwiesen. Wir korrelierten die Lokalisation und Anzahl der PSMA-positiven Läsionen mit der Therapiewahl nach der Bildgebung. Die Detektionsraten wurden nach den PSA-Werten zum Zeitpunkt der PET/CT stratifiziert. Das Studiendesign war monozentrisch-retrospektiv.

Ergebnisse 34 Patienten (30,9 %) hatten einen PSMA-negativen Scan, während 17 (15,5 %) ein lokales Rezidiv und 59 (53,6 %) ein metastasiertes Rezidiv in der PSMA-PET hatten. In der ROC-Analyse erwies sich eine Anzahl von ≤3 Metastasen in der PSMA-PET als Schwellenwert für die Verfolgung einer MDT statt einer ausschließlich systemischen Therapie (AUC: 0,88). Definiert als 3 oder weniger Metastasen wurde das oligometastatisch rezidivierte PCa bei bis zu 30% (33/110) aller Patienten vorgefunden. Bei PSA-Werten unter 3,5 ng/ml lag die Rate der PSMA-positiven Befunde, die lokal begrenzt oder oligometastatisch waren, bei 76 % (45/59) und sank signifikant auf 29,4 % (5/17) oberhalb dieses Grenzwerts (p<0,001), da polymetastatische Befunde zunahmen.

Schlussfolgerung Der Nachweis von ≤3 PCa-Oligometastasen in der PSMA-PET ermutigte zur Verfolgung einer lokalen, Metastasen-gerichteten anstelle einer rein systemischen Therapiestrategie. Die PSMA-PET erfasste die Patienten in Rezidivstadien, die einer lokalen Therapie zugänglich waren, vor allem dann, wenn die Bildgebung bei PSA-Werten unter 3,5 ng/ml veranlasst wurde.

Schlüsselwörter

Prostatakarzinom - PSMA PET/CT - Biochemisches Rezidiv - oligometastatisch - Metastasen-gerichtete Therapie - PSA

Keywords

prostate cancer - PSMA PET/CT - Biochemical recurrence - Oligometastatic - Metastasis-directed therapy - PSA

Publication History

Received: 10 May 2021

Accepted after revision: 15 November 2021

Article published online:
06 April 2022

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