Prof. Georg Salomon (DE) and Dr. Jochen Walz (FR) chaired the session, which also covered topics on the enhancement of access to radiotheranostics for cancer care through the Oncidium initiative, as well as the different tracers for various indications in every cancer type.

In her presentation, “Current challenges of PSMA PET/CT in prostate cancer”, Assoc. Prof. Daniela Oprea-Lager (NL) cited the EAU Guidelines on Prostate Cancer, which stated PSMA PET/CT is more accurate for staging than CT and bone scan for high-risk disease but to date, no outcome data exists to inform subsequent management.

One of the recommendations of the EAU Guidelines with a “Strong” strength rating was when using PSMA PET or whole-body MRI to increase sensitivity, be aware of the lack of outcome data of subsequent treatment changes.

Assoc. Prof. Oprea-Lager concluded, “We cannot ignore modern imaging techniques and continue re(staging) and treating disease as we did in the era of conventional imaging.” She added that clinical outcomes such as overall survival, disease recurrence, and quality of life should be proven first. Learning how to interpret modern imaging properly and how to treat patients is imperative.

View the session recap and watch the full presentations on the EMUC23 Resource Centre.

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In his pre-recorded lecture “Optimal staging approach in men recurring after primary treatment”, Prof. Declan Murphy (AU) stated, “There is no role for imaging in patients with PSA > 0.2 ng/mL detectable on an ultrasensitive assay.”

He cited three publications (1) which confirmed that the cancer benefit of waiting for PSA to reach 0.2 ng/mL first and then offering salvage radiotherapy is as good as providing adjuvant radiotherapy when the PSA is below 0.2 ng/mL. Moreover, it is less toxic and overtreatment can be avoided. He added that imaging may have a role within the range of 0.2 ng/mL up to about 2 ng/mL.

According to Prof. Murphy, conventional imaging such as CT and bone scan is pointless in these low-range settings. “Please don’t do a CT and bone scan when the PSA climbs above 0.2 ng/mL even just to reassure your anxious patients. MRI has a role for staging loco-regional recurrence especially if novel imaging is unavailable.”

He underscored that PSMA PET/CT is the best imaging tool for biochemical recurrence as it is the most sensitive and the most specific imaging modality for biochemical recurrence for PCA patients. “Use PSMA PET/CT once the PSA is above 0.2 ng/mL as it may change your management.”

Prof. Murphy referred back to the findings of the aforementioned three publications (1) which collectively substantiated that PSMA PET/CT has an impressive sensitivity for detecting disease in men with biochemical recurrence even at very low PSA levels of < 1 ng/mL with specificity well above 90%. He added, “PSMA PET/CT offers a safe, one-stop whole-body scan with excellent tumour-to-background-contrast ratio.”

Treatment monitoring

Following Prof. Murphy’s presentation was the lecture of radiologist Dr. Ekaterini Tavermaraki (GR) entitled “How to use imaging for treatment monitoring in metastatic prostate cancer”.

Dr. Tavermaraki stated that conventional imaging still has a role in the follow-up of patients under systemic treatment. She added that modern PSMA PET/CT imaging techniques provide better sensitivity and specificity for metastases detection, especially in biochemical recurrence in low values of PSA. Subcentimeter-target lesions which are not measurable at CT, are visualized. PSMA PET/CT imaging provides earlier response information than anatomic imaging methods.

She also mentioned the pitfalls of PSMA PET/CT which include low to moderate PSMA expression in osteoblastic activity, moderate uptake in haemangiomas, and chronic inflammation can also be associated with PSMA uptake. She stated, “All of these cases correlate with anatomic findings. If there is uncertainty, ongoing monitoring of the PSA level with follow-up PSMA PET is suggested.”

In addition, the limitation of PSMA PET/CT is that if the primary tumour is not PSMA-avid, the sensitivity for detecting nodal or distant metastatic disease will be lower, and closer attention must be given to anatomic review.

Watch the full presentations of Prof. Murphy and Dr. Tavermaraki and other must-view presentations of Plenary Session 1 via the Resource Centre.

References:

• Gallium-68 Prostate-specific Membrane Antigen Positron Emission Tomography in Advanced Prostate Cancer-Updated Diagnostic Utility, Sensitivity, Specificity, and Distribution of Prostate-specific Membrane Antigen-avid Lesions: A Systematic Review and Meta-analysis (Perrera et al, Eur Urol 2020)
• Assessment of 68Ga-PSMA-11 PET Accuracy in Localizing Recurrent Prostate Cancer: A Prospective Single-Arm Clinical Trial (Fendler, Calais, Eiber, et al., JAMA Oncol 2019)
• Diagnostic Performance of 18F-DCFPyL-PET/CT in Men with Biochemically Recurrent Prostate Cancer: Results from the CONDOR Phase III, Multicenter Study (Morris et al., Clin Can Res 2021)

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