Prediction nomogram for 68Ga-PSMA-11 PET/CT in different clinical settings of PSA failure after radical treatment for prostate cancer

  • Francesco CeciEmail author
  • Lorenzo Bianchi
  • Marco Borghesi
  • Giulia Polverari
  • Andrea Farolfi
  • Alberto Briganti
  • Riccardo Schiavina
  • Eugenio Brunocilla
  • Paolo Castellucci
  • Stefano Fanti
Original Article
Part of the following topical collections:
  1. Oncology – Genitourinary



The objective of this study was to develop a clinical nomogram to predict gallium-68 prostate-specific membrane antigen positron emission tomography/computed tomography (68Ga-PSMA-11-PET/CT) positivity in different clinical settings of PSA failure.

Materials and methods

Seven hundred three (n = 703) prostate cancer (PCa) patients with confirmed PSA failure after radical therapy were enrolled. Patients were stratified according to different clinical settings (first-time biochemical recurrence [BCR]: group 1; BCR after salvage therapy: group 2; biochemical persistence after radical prostatectomy [BCP]: group 3; advanced-stage PCa before second-line systemic therapies: group 4).

First, we assessed 68Ga-PSMA-11-PET/CT positivity rate. Second, multivariable logistic regression analyses were used to determine predictors of positive scan. Third, regression-based coefficients were used to develop a nomogram predicting positive 68Ga-PSMA-11-PET/CT result and 200 bootstrap resamples were used for internal validation. Fourth, receiver operating characteristic (ROC) analysis was used to identify the most informative nomogram’s derived cutoff. Decision curve analysis (DCA) was implemented to quantify nomogram’s clinical benefit.


68Ga-PSMA-11-PET/CT overall positivity rate was 51.2%, while it was 40.3% in group 1, 54% in group 2, 60.5% in group 3, and 86.9% in group 4 (p < 0.001). At multivariable analyses, ISUP grade, PSA, PSA doubling time, and clinical setting were independent predictors of a positive scan (all p ≤ 0.04). A nomogram based on covariates included in the multivariate model demonstrated a bootstrap-corrected accuracy of 82%. The nomogram-derived best cutoff value was 40%. In DCA, the nomogram revealed clinical net benefit of > 10%.


This novel nomogram proved its good accuracy in predicting a positive scan, with values ≥ 40% providing the most informative cutoff in counselling patients to 68Ga-PSMA-11-PET/CT. This tool might be important as a guide to clinicians in the best use of PSMA-based PET imaging.


Prostate cancer Biochemical recurrence Biochemical persistence PSMA PET Nomogram Prediction 



Authors would thank Alessandro Lambertini MD (Nuclear Medicine, S.Orsola-Malpighi University of Bologna) for his contribution in final linguistic review.

Compliance with ethical standards

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the principles of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Conflict of interest

The authors declare that there is no conflict of interest.

Supplementary material

259_2019_4505_MOESM1_ESM.png (314 kb)
Supplementary Figure 1 Receiver-operator characteristic (ROC) and area under curve (AUC) of the nomogram in overall population to predict positive 68Ga-PSMA-11-PET/CT results (AUC=0.82; 95%CI=0.79-0.85). (JPEG 60 kb)
259_2019_4505_MOESM2_ESM.png (1.2 mb)
Supplementary Figure 2 Receiver-operator characteristic (ROC) and area under curve (AUC) of each nomogram derived cut-off to predict positive 68Ga-PSMA-11-PET/CT results. The best nomogram’s cut-off to predict positive scan was 40% (AUC=0.76; 95%CI=0.72-0.79). (JPEG 147 kb)
259_2019_4505_MOESM3_ESM.docx (18 kb)
Supplementary Table 1 Univariate and multivariate logistic regression to predict positive findings at 68Ga-PSMA-11-PET/CT in Group-1 (n=325) (DOCX 17 kb)
259_2019_4505_MOESM4_ESM.docx (17 kb)
Supplementary Table 2 Univariate and multivariate logistic regression to predict positive findings at 68Ga-PSMA-11-PET/CT in Group-2 (n=241) (DOCX 17 kb)
259_2019_4505_MOESM5_ESM.docx (17 kb)
Supplementary Table 3 Univariate and multivariate logistic regression to predict positive findings at 68Ga-PSMA-11-PET/CT in Group-3 (n=76) (DOCX 16 kb)
259_2019_4505_MOESM6_ESM.docx (16 kb)
Supplementary Table 4 Univariate and multivariate logistic regression to predict positive findings at 68Ga-PSMA-11-PET/CT in Group-4 (n=61) (DOCX 16 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Francesco Ceci
    • 1
    • 2
    • 3
    Email author
  • Lorenzo Bianchi
    • 3
    • 4
  • Marco Borghesi
    • 3
    • 4
  • Giulia Polverari
    • 1
  • Andrea Farolfi
    • 1
  • Alberto Briganti
    • 5
  • Riccardo Schiavina
    • 3
    • 4
  • Eugenio Brunocilla
    • 3
    • 4
  • Paolo Castellucci
    • 1
  • Stefano Fanti
    • 1
  1. 1.Metropolitan Nuclear Medicine, S.Orsola-Malpighi HospitalUniversity of BolognaBolognaItaly
  2. 2.Nuclear Medicine, AOU Città della Salute e della Scienza di Torino, Department of Medical SciencesUniversity of TurinTurinItaly
  3. 3.Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Cardio-Nephro-Thoracic Sciences DoctorateUniversity of BolognaBolognaItaly
  4. 4.Department of Urology, S.Orsola-Malpighi HospitalUniversity of BolognaBolognaItaly
  5. 5.Unit of Urology/Division of Oncology, Urological Research InstituteIRCCS San Raffaele HospitalMilanItaly

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