68Ga-PSMA PET/CT better characterises localised prostate cancer after MRI and transperineal prostate biopsy: Is 68Ga-PSMA PET/CT guided biopsy the future?

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68Ga prostate specific membrane antigen PET/CT (68Ga-PSMA PET/CT) may be superior to multiparametric MRI (mpMRI) for localisation of prostate cancer tumour foci, however the concordance and differences between 68Ga-PSMA PET/CT and mpMRI when applied to all biopsied patients and potential benefit in patients with negative mpMRI is unclear.


Retrospective analysis of patients undergoing mpMRI, prostate biopsy and 68Ga-PSMA PET/CT over a 3-year period. Diagnostic performance of 68Ga-PSMA PET/CT and mpMRI were assessed using biopsy histopathology for the entire cohort and radical prostatectomy specimen in a subset of patients. Lesion concordance and additional detection of each modality were determined, including in a dedicated cohort of patients with mpMRI PIRADS 2 scans.


A total of 144 patients were included in the study. Index lesion/foci detection was similar between 68Ga-PSMA PET/CT and mpMRI (sensitivity 83.1% vs 90.1%; p = 0.267), however lesions missed by mpMRI were larger (1.66 cm3 vs 0.72 cm3; p = 0.034). Lesion detection rates were similar across the biopsy histopathology and radical prostatectomy specimen subset, with a high concordance for index (80.1%) and a moderate concordance for total (67%) lesions between the 2 imaging modalities. The additional detection yield favoured 68Ga-PSMA PET/CT over mpMRI for index (13.5% vs 4.3%) and total (18.2% vs 5.4%) lesions; both modalities missed 2.1% and 12.3% of index and total lesions, respectively. 68Ga-PSMA PET/CT identified 9 of 11 patients with PIRADS 2 mpMRI but subsequently diagnosed with Gleason ≥ 3 + 4 disease.


Despite high concordance rates, 68Ga-PSMA PET/CT incrementally improved tumour localisation compared with mpMRI. These results suggest that 68Ga-PSMA PET/CT may have an incremental value to that of mpMRI in the diagnostic process for prostate.

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  1. 1.

    Ahmed HU, El-Shater Bosaily A, Brown LC, Gabe R, Kaplan R, Parmar MK, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet. 2017;389(10071):815–22.

  2. 2.

    Kasivisvanathan V, Rannikko AS, Borghi M, Panebianco V, Mynderse LA, Vaarala MH, et al. MRI-targeted or standard biopsy for prostate-cancer diagnosis. N Engl J Med. 2018;378(19):1767–77.

  3. 3.

    Donato P, Morton A, Yaxley J, Teloken PE, Coughlin G, Esler R, et al. Improved detection and reduced biopsies: the effect of a multiparametric magnetic resonance imaging-based triage prostate cancer pathway in a public teaching hospital. World J Urol. 2019.

  4. 4.

    Baco E, Rud E, Eri LM, Moen G, Vlatkovic L, Svindland A, et al. A randomized controlled trial to assess and compare the outcomes of two-core prostate biopsy guided by fused magnetic resonance and transrectal ultrasound images and traditional 12-core systematic biopsy. Eur Urol. 2016;69(1):149–56.

  5. 5.

    Le JD, Tan N, Shkolyar E, Lu DY, Kwan L, Marks LS, et al. Multifocality and prostate cancer detection by multiparametric magnetic resonance imaging: correlation with whole-mount histopathology. Eur Urol. 2015;67(3):569–76.

  6. 6.

    Moore CM, Robertson NL, Arsanious N, Middleton T, Villers A, Klotz L, et al. Image-guided prostate biopsy using magnetic resonance imaging-derived targets: a systematic review. Eur Urol. 2013;63(1):125–40.

  7. 7.

    Radtke JP, Schwab C, Wolf MB, Freitag MT, Alt CD, Kesch C, et al. Multiparametric magnetic resonance imaging (MRI) and MRI–transrectal ultrasound fusion biopsy for index tumor detection: correlation with radical prostatectomy specimen. Eur Urol. 2016;70(5):846–53.

  8. 8.

    Borofsky S, George AK, Gaur S, Bernardo M, Greer MD, Mertan FV, et al. What are we missing? False-negative cancers at multiparametric MR imaging of the prostate. Radiology. 2018;286(1):186–95.

  9. 9.

    Dianat SS, Carter HB, Macura KJ. Performance of multiparametric magnetic resonance imaging in the evaluation and management of clinically low-risk prostate cancer. Urol Oncol: Seminars Orig Investig. 2014;32(1):39.e1–e10.

  10. 10.

    Priester A, Natarajan S, Khoshnoodi P, Margolis DJ, Raman SS, Reiter RE, et al. Magnetic resonance imaging underestimation of prostate cancer geometry: use of patient specific molds to correlate images with whole mount pathology. J Urol. 2017;197(2):320–6.

  11. 11.

    Perera M, Papa N, Roberts M, Williams M, Udovicich C, Vela I, et al. 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. Eur Urol. 2019.

  12. 12.

    Afshar-Oromieh A, Haberkorn U, Schlemmer HP, Fenchel M, Eder M, Eisenhut M, et al. Comparison of PET/CT and PET/MRI hybrid systems using a 68Ga-labelled PSMA ligand for the diagnosis of recurrent prostate cancer: initial experience. Eur J Nucl Med Mol Imaging. 2014;41(5):887–97.

  13. 13.

    Meredith G, Wong D, Yaxley J, Coughlin G, Thompson L, Kua B, et al. The use of 68 Ga-PSMA PET CT in men with biochemical recurrence after definitive treatment of acinar prostate cancer. BJU Int. 2016;118(S3):49–55.

  14. 14.

    Rauscher I, Duwel C, Haller B, Rischpler C, Heck MM, Gschwend J, et al. Efficacy, predictive factors, and prediction nomograms for Ga-68-labeled prostate-specific membrane antigen-ligand positron-emission tomography/computed tomography in early biochemical recurrent prostate cancer after radical prostatectomy. Eur Urol. 2018;73(5):656–61.

  15. 15.

    Yaxley JW, Raveenthiran S, Nouhaud F-X, Samaratunga H, Yaxley WJ, Coughlin G, et al. Risk of metastatic disease on 68gallium-prostate-specific membrane antigen positron emission tomography/computed tomography scan for primary staging of 1253 men at the diagnosis of prostate cancer. BJU Int.

  16. 16.

    Yaxley JW, Raveenthiran S, Nouhaud FX, Samartunga H, Yaxley AJ, Coughlin G, et al. Outcomes of primary lymph node staging of intermediate and high risk prostate cancer with (68)Ga-PSMA positron emission tomography/computerized tomography compared to histological correlation of pelvic lymph node pathology. J Urol. 2019;201(4):815–20.

  17. 17.

    Eiber M, Weirich G, Holzapfel K, Souvatzoglou M, Haller B, Rauscher I, et al. Simultaneous (68)Ga-PSMA HBED-CC PET/MRI improves the localization of primary prostate cancer. Eur Urol. 2016;70(5):829–36.

  18. 18.

    Rahbar K, Weckesser M, Huss S, Semjonow A, Breyholz HJ, Schrader AJ, et al. Correlation of intraprostatic tumor extent with (6)(8)Ga-PSMA distribution in patients with prostate cancer. J Nucl Med. 2016;57(4):563–7.

  19. 19.

    Woythal N, Arsenic R, Kempkensteffen C, Miller K, Janssen J-C, Huang K, et al. Immunohistochemical validation of PSMA expression measured by 68Ga-PSMA PET/CT in primary prostate cancer. J Nuclear Med. 2018;59(2):238.

  20. 20.

    Donato P, Roberts MJ, Morton A, Kyle S, Coughlin G, Esler R, et al. Improved specificity with 68 Ga PSMA PET/CT to detect clinically significant lesions “invisible” on multiparametric MRI of the prostate: a single institution comparative analysis with radical prostatectomy histology. Eur J Nucl Med Mol Imaging. 2018:<xocs:firstpage xmlns:xocs=""/>.

  21. 21.

    Pokorny MR, de Rooij M, Duncan E, Schroder FH, Parkinson R, Barentsz JO, et al. Prospective study of diagnostic accuracy comparing prostate cancer detection by transrectal ultrasound-guided biopsy versus magnetic resonance (MR) imaging with subsequent MR-guided biopsy in men without previous prostate biopsies. Eur Urol. 2014;66(1):22–9.

  22. 22.

    Epstein JI, Egevad L, Amin MB, Delahunt B, Srigley JR, Humphrey PA. The 2014 International Society of Urological Pathology (ISUP) consensus conference on Gleason grading of prostatic carcinoma: definition of grading patterns and proposal for a new grading system. Am J Surg Pathol. 2016;40(2):244–52.

  23. 23.

    Futterer JJ, Briganti A, De Visschere P, Emberton M, Giannarini G, Kirkham A, et al. Can clinically significant prostate cancer be detected with multiparametric magnetic resonance imaging? A systematic review of the literature. Eur Urol. 2015;68(6):1045–53.

  24. 24.

    van der Kwast TH, Amin MB, Billis A, Epstein JI, Griffiths D, Humphrey PA, et al. International Society of Urological Pathology (ISUP) consensus conference on handling and staging of radical prostatectomy specimens. Working group 2: T2 substaging and prostate cancer volume. Mod Pathol. 2010;24:16.

  25. 25.

    Chen M, Zhang Q, Zhang C, Zhao X, Marra G, Gao J, et al. Combination of 68Ga-PSMA PET/CT and multiparameter MRI improves the detection of clinically significant prostate cancer: a lesion by lesion analysis. J Nucl Med. 2018.

  26. 26.

    Rhee H, Thomas P, Shepherd B, Gustafson S, Vela I, Russell PJ, et al. Prostate specific membrane antigen positron emission tomography may improve the diagnostic accuracy of multiparametric magnetic resonance imaging in localized prostate cancer. J Urol. 2016;196(4):1261–7.

  27. 27.

    Kalapara AA, Nzenza T, Pan HY, Ballok Z, Ramdave S, O'Sullivan R, et al. Detection and localisation of primary prostate cancer using 68Ga-PSMA PET/CT compared with mpMRI and radical prostatectomy specimens. BJU Int.

  28. 28.

    Kasivisvanathan V, Dufour R, Moore CM, Ahmed HU, Abd-Alazeez M, Charman SC, et al. Transperineal magnetic resonance image targeted prostate biopsy versus transperineal template prostate biopsy in the detection of clinically significant prostate cancer. J Urol. 2013;189(3):860–6.

  29. 29.

    Kasivisvanathan V, Stabile A, Neves JB, Giganti F, Valerio M, Shanmugabavan Y, et al. Magnetic resonance imaging-targeted biopsy versus systematic biopsy in the detection of prostate cancer: a systematic review and meta-analysis. Eur Urol. 2019.

  30. 30.

    Coker MA, Glaser ZA, Gordetsky JB, Thomas JV, Rais-Bahrami S. Targets missed: predictors of MRI-targeted biopsy failing to accurately localize prostate cancer found on systematic biopsy. Prostate Cancer Prostatic Dis. 2018.

  31. 31.

    Johnson DC, Raman SS, Mirak SA, Kwan L, Bajgiran AM, Hsu W, et al. Detection of individual prostate cancer foci via multiparametric magnetic resonance imaging. Eur Urol. 2019;75(5):712–20.

  32. 32.

    Houlahan KE, Salmasi A, Sadun TY, Pooli A, Felker ER, Livingstone J, et al. Molecular hallmarks of multiparametric magnetic resonance imaging visibility in prostate cancer. Eur Urol. 2019;76(1):18–23.

  33. 33.

    Eiber M, Weirich G, Holzapfel K, Souvatzoglou M, Haller B, Rauscher I, et al. Simultaneous 68Ga-PSMA HBED-CC PET/MRI improves the localization of primary prostate cancer. Eur Urol. 2016;70(5):829–36.

  34. 34.

    Scheltema MJ, Chang JI, Stricker PD, van Leeuwen PJ, Nguyen QA, Ho B, et al. Diagnostic accuracy of (68) Ga-prostate-specific membrane antigen (PSMA) positron-emission tomography (PET) and multiparametric (mp) MRI to detect intermediate-grade intra-prostatic prostate cancer using whole-mount pathology: impact of the addition of (68) Ga-PSMA PET to mpMRI. BJU Int. 2019.

  35. 35.

    Roberts MJ, Bennett HY, Harris PN, Holmes M, Grummet J, Naber K, et al. Prostate biopsy-related infection: a systematic review of risk factors, prevention strategies, and management approaches. Urology. 2017;104:11–21.

  36. 36.

    Hupe MC, Philippi C, Roth D, Kümpers C, Ribbat-Idel J, Becker F, et al. Expression of prostate-specific membrane antigen (PSMA) on biopsies is an independent risk stratifier of prostate cancer patients at time of initial diagnosis. Front Oncol. 2018;8:623.

  37. 37.

    van Leeuwen PJ, Donswijk M, Nandurkar R, Stricker P, Ho B, Heijmink S, et al. Gallium-68-prostate-specific membrane antigen ((68) Ga-PSMA) positron emission tomography (PET)/computed tomography (CT) predicts complete biochemical response from radical prostatectomy and lymph node dissection in intermediate- and high-risk prostate cancer. BJU Int. 2018.

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Correspondence to Peter Donato or Matthew J Roberts.

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The study was approved by the Ethics Committee of the Royal Brisbane and Women’s Hospital (RBWH) Human Research Ethics Committee (approval number HREC/17/QRBW/644).

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Informed consent was not deemed necessary by the Ethics Committee of the Royal Brisbane and Women’s Hospital (RBWH) Human Research Ethics Committee.

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Donato, P., Morton, A., Yaxley, J. et al. 68Ga-PSMA PET/CT better characterises localised prostate cancer after MRI and transperineal prostate biopsy: Is 68Ga-PSMA PET/CT guided biopsy the future?. Eur J Nucl Med Mol Imaging (2020).

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  • Prostatic neoplasms
  • Positron-emission tomography
  • Magnetic resonance imaging
  • Glutamate carboxypeptidase II
  • Human
  • Prostatectomy
  • Prostate specific membrane antigen