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Comparison of 68 Ga-PSMA ligand PET/CT versus conventional cross-sectional imaging for target volume delineation for metastasis-directed radiotherapy for metachronous lymph node metastases from prostate cancer

Vergleich von 68 Ga-PSMA-Liganden-PET/CT und konventioneller Schnittbildgebung zur Zielvolumendefinition für die metastasengerichtete Strahlentherapie bei metachronen Lymphknotenmetastasen durch Prostatakrebs

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Abstract

Purpose

To assess the differences in the target volume (TV) delineation of metachronous lymph node metastases between 68 Ga-PSMA ligand PET/CT and conventional imaging in a comparative retrospective contouring study.

Patients and methods

Twenty-five patients with biochemical prostate cancer recurrence after primary prostatectomy underwent 68 Ga-PSMA ligand PET/CT in addition to conventional imaging techniques such as CT and/or MR imaging for restaging. All patients were diagnosed with at least one lymph node metastasis. TVs were manually delineated in two different ways: (a) based on conventional imaging (CT/MRI) and (b) based on conventional imaging (CT/MRI) plus 68 Ga-PSMA ligand PET/CT. The size of TVs, overlap rates, and subjective assessment of the difficulty of TV delineation reported by the radiation oncologist (easy/moderate/difficult) were compared.

Results

With the additional information from PSMA ligand PET, 47 lymph node metastases were identified and included in the gross tumor volume (GTV). The median clinical target volume (CTV) of non-PET-based TV delineation was statistically larger than the CTV based on PET imaging (134.8 ml [range 6.9–565.2] versus 44.9 ml [range 4.9–481.3; p = 0.001]). The CTV based on CT/MRI enclosed only 81.3% (39/48) of PET-positive lymph nodes. The CT/MRI-based CTV did not enclose all PET-positive lymph nodes in 24% (6/25) of patients. In 12% (3/25) of patients, all PET-positive lymph nodes were outside of the CT/MRI-based CTV. The median overlap rates (TVPET/TVCT/MRI × 100) were 45.7% (range 0–96.9) for the GTV and 71.7% (range 9.8–98.2) for the CTV. The assessment of difficulty of contouring revealed that contouring with the additional imaging information of the PET was categorized as easy/moderate in 92% (23/25) and as difficult in 8% (2/25) of the cases, whereas contouring based on CT/MRI without PET was categorized as difficult in 56% (14/25) and as easy/moderate in 44% of the cases (11/25; p = 0.003).

Conclusion

68 Ga-PSMA ligand PET/CT is superior to conventional cross-sectional imaging for the delineation of lymph node metastases from prostate cancer. PET-based TV delineation allows for smaller target volumes and should be considered the standard for irradiation of metachronous lymph node metastases in recurrent prostate cancer. Conventional imaging is not sufficiently sensitive for radio-oncological treatment concepts in oligometastatic prostate cancer.

Zusammenfassung

Ziel

Die Untersuchung von Unterschieden bei Zielvolumina (ZV) für metachrone Lymphknotenmetastasen zwischen 68 Ga-PSMA-Liganden-PET/CT und konventioneller Bildgebung in einer vergleichenden retrospektiven Konturierungsstudie.

Patienten und Methoden

Fünfundzwanzig Patienten mit biochemischem Rezidiv nach primärer Prostatektomie erhielten zusätzlich zur konventionellen Bildgebung (Computertomographie [CT] und/oder Magnetresonanstomographie [MRT]) ein 68 Ga-PSMA-Liganden-PET/CT zum Re-Staging. Bei allen Patienten wurde mindestens eine Lymphknotenmetastasierung diagnostiziert. Die ZVs wurden auf zwei Wegen konturiert: (a) basierend auf konventioneller Bildgebung (CT/MRT) und (b) basierend auf konventioneller Bildgebung plus 68 Ga-PSMA-Liganden-PET/CT. Die Größe der ZVs, die Überlappungsrate und die subjektive Einschätzung des Schwierigkeitsgrads durch die Strahlentherapeuten (leicht/moderat/schwer) wurden miteinander verglichen.

Ergebnisse

Durch die zusätzliche bildgebende Information der PSMA-Liganden-PET wurden alle 47 Lymphknotenmetastasen korrekt als maligne identifiziert und in das „gross tumor volume“ (GTV) einbezogen. Das klinische Zielvolumen (CTV) des nicht-PET-basierten Konturierens war signifikant größer als das CTV auf PET-Basis (134,8 ml [Spanne 6,9–565,2 ml] versus 44,9 ml [Spanne 4,9–481,3 ml]; p = 0,001). Das CTV auf Basis von CT/MRT umschloss 80,9% (38/47) der PSMA-positiven Lymphknoten. Bei 24% der Patienten (6/25) waren nicht alle der PSMA-PET-positiven Lymphknotenmetastasen vom CTV umschlossen und bei 12% (3/25) lagen alle Lymphknotenmetastasen außerhalb des CTV. Die mediane Überlappungsrate (ZVPET/ZVCT/MRT × 100) betrug 45,7% (Spanne 0–96,9%) für das GTV bzw. 71,7% (Spanne 9,8–98,2%) für das CTV. Bezüglich der Einschätzung des Schwierigkeitsgrads wurde das Konturieren mit zusätzlicher PET-Information in 92% (23/25) als leicht bis moderat und in 8% (2/25) als schwierig kategorisiert, wohingegen dies ohne PET nur auf Basis von CT/MRT in 56% (14/25) als schwer und in 44% (11/25; p = 0,003) als leicht bis moderat eingeschätzt wurde.

Schlussfolgerung

Das 68 Ga-PSMA-Liganden-PET/CT ist der konventionellen Schnittbildgebung zur Konturierung von morphologisch vergrößerten Lymphknotenmetastasen überlegen. Das PET-basierte Konturieren erlaubt zudem kleinere ZV und sollte daher als Standard für die Bestrahlungsplanung von metachronen Lymphknotenmetastasen des rezidivierten Prostatakarzinoms gelten. Konventionelle Bildgebung ist für radioonkologische Behandlungskonzepte bei oligometastasiertem Prostatakarzinom nicht ausreichend sensibel.

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Acknowledgements

We thank Bernhard Vaske for his statistical support and review of the statistical results.

Author information

Authors and Affiliations

  1. Department of Radiation Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany

    Daniel Walacides M.D., Astrid Meier M.D., Anne Caroline Knöchelmann M.D., Daniele Meinecke M.D., Hans Christiansen M.D. & Christoph Henkenberens M.D.

  2. Department of Urology and Urologic Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany

    Markus A. Kuczyk M.D. & Christoph A. J. von Klot M.D.

  3. Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany

    Thorsten Derlin M.D., Frank M. Bengel M.D. & Tobias L. Ross PhD

  4. Pharmaceutical Radiochemistry, Technical University Munich, Walther-Meißner-Str. 3, 85748, Garching, Germany

    Hans-Jürgen Wester PhD

  5. Department of Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany

    Katja Derlin M.D.

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  1. Daniel Walacides M.D.
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Corresponding author

Correspondence to Christoph Henkenberens M.D..

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Conflict of interest

D. Walacides is a shareholder of Scintomics. A. Meier, A.C. Knöchelmann, D. Meinecke, T. Derlin,F.M. Bengel, T.L. Ross, H.-J. Wester, K. Derlin, M.A. Kuczyk,C.A.J. von Klot, H. Christiansen, and C. Henkenberens declare that they have no competing interests.

Ethical standards

All patients provided written informed consent prior to 68 Ga-PSMA ligand PET/CT, CT, or MRI. This retrospective study complied with the regulations of the local institutional review board and principles of the Declaration of Helsinki.

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Walacides, D., Meier, A., Knöchelmann, A.C. et al. Comparison of 68 Ga-PSMA ligand PET/CT versus conventional cross-sectional imaging for target volume delineation for metastasis-directed radiotherapy for metachronous lymph node metastases from prostate cancer. Strahlenther Onkol 195, 420–429 (2019). https://doi.org/10.1007/s00066-018-1417-9

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