Detection of metastases in newly diagnosed prostate cancer by using 68Ga-PSMA PET/CT and its relationship with modified D’Amico risk classification

A Correction to this article was published on 07 April 2021

This article has been updated



We aimed to investigate the diagnostic power of 68Ga-PSMA PET/CT in the detection of metastatic spread of newly diagnosed PCa, and evaluate the relationship with modified D’Amico risk classification.


We evaluated newly diagnosed PCa patients who underwent 68Ga-PSMA PET/CT prior to therapy. All images were interpreted retrospectively and areas of abnormally increased tracer uptake were documented according to PSMA-RADS version 1.0 system. Patients were divided into risk groups as low, intermediate, or high risk, according to a modification in D’Amico classification system as ISUP grade 3 tumors were included to high-risk group. 68Ga-PSMA PET/CT findings were compared among risk groups as well as PSA levels, clinical T stages, and ISUP grades.


A total of 356 patients were included to the study with a median PSA level was 16.42 (1.29–7013) ng/ml and median Gleason score was 8 (range: 6–10). Of these, 13(3.7%), 54 (15.1%), and 289 (81.2%) were in the low-, intermediate-, and high-risk groups, respectively. Lymph node metastases were detected in 125 (35.1%) patients, and in 48 of them, metastasis was limited to pelvic lymph nodes (PLN). Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated as 71.4%, 100%, 95.9%, 100%, and 95.4%, respectively for the detection of PLN, based on histopathological results of 49 patients. Overall, any metastasis was detected in 47.7% of high-risk patients, while only PLN metastases were defined in 3.7% intermediate-risk patients and none of low-risk patients had any kind of metastasis.


This study revealed that 68Ga-PSMA PET/CT should be routinely used in newly diagnosed high-risk PCa patients; whereas it seems to be of limited use for intermediate-risk group and useless for the low-risk group.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Change history


  1. 1.

    Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin. 2017;67:7–30.

    PubMed  Article  Google Scholar 

  2. 2.

    Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol. 2009;27:2758–65.

    PubMed  Article  Google Scholar 

  3. 3.

    Arnold M, Karim-Kos HE, Coebergh JW, Byrnes G, Antilla A, Ferlay J, et al. Recent trends in incidence of five common cancers in 26 European countries since 1988: analysis of the European Cancer Observatory. Eur J Cancer. 2015;51:1164–87.

    PubMed  Article  Google Scholar 

  4. 4.

    Cheng L, Montironi R, Bostwick DG, Lopez-Beltran A, Berney DM. Staging of prostate cancer. Histopathology. 2012;60:87–117.

    PubMed  Article  Google Scholar 

  5. 5.

    Mottet N, Cornford P, van den Bergh R. EAU-EANM-ESTRO-ESUR-SIOG guidelines on prostate cancer, version 2020.

  6. 6.

    Hövels A, Heesakkers R, Adang E, Jager G, Strum S, Hoogeveen Y, et al. The diagnostic accuracy of CT and MRI in the staging of pelvic lymph nodes in patients with prostate cancer: a meta-analysis. Clin Radiol. 2008;63:387–95.

    PubMed  Article  Google Scholar 

  7. 7.

    Abuzallouf S, Dayes I, Lukka H. Baseline staging of newly diagnosed prostate cancer: a summary of the literature. J Urol. 2004;171:2122–7.

    PubMed  Article  Google Scholar 

  8. 8.

    Pound CR, Partin AW, Epstein JI, Walsh PC. Prostate-specific antigen after anatomic radical retropubic prostatectomy: patterns of recurrence and cancer control. Urol Clin N Am. 1997;24:395–406.

    CAS  Article  Google Scholar 

  9. 9.

    Sweat SD, Pacelli A, Murphy GP, Bostwick DG. Prostate-specific membrane antigen expression is greatest in prostate adenocarcinoma and lymph node metastases. Urology. 1998;52:637–40.

    CAS  PubMed  Article  Google Scholar 

  10. 10.

    Maurer T, Gschwend JE, Rauscher I, Souvatzoglou M, Haller B, Weirich G, et al. Diagnostic efficacy of 68gallium-PSMA positron emission tomography compared to conventional imaging for lymph node staging of 130 consecutive patients with intermediate to high risk prostate cancer. J Urol. 2016;195:1436–43.

    PubMed  Article  Google Scholar 

  11. 11.

    Afshar-Oromieh A, Holland-Letz T, Giesel FL, Kratochwil C, Mier W, Haufe S, et al. Diagnostic performance of 68 Ga-PSMA-11 (HBED-CC) PET/CT in patients with recurrent prostate cancer: evaluation in 1007 patients. Eur J Nucl Med Mol Imaging. 2017;44:1258–68.

    PubMed  PubMed Central  Article  Google Scholar 

  12. 12.

    Calais J, Czernin J, Cao M, Kishan AU, Hegde JV, Shaverdian N, et al. 68Ga-PSMA-11 PET/CT mapping of prostate Cancer biochemical recurrence after radical prostatectomy in 270 patients with a PSA level of less than 1.0 ng/mL: impact on salvage radiotherapy planning. J Nucl Med. 2018;59:230–7.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  13. 13.

    Eiber M, Maurer T, Souvatzoglou M, Beer AJ, Ruffani A, Haller B, et al. Evaluation of hybrid 68Ga-PSMA ligand PET/CT in 248 patients with biochemical recurrence after radical prostatectomy. J Nucl Med. 2015;56:668–74.

    PubMed  Article  Google Scholar 

  14. 14.

    Tan N, Bavadian N, Calais J, Oyoyo U, Kim J, Turkbey IB, et al. Imaging of PSMA-targeted radiotracers for the detection of prostate cancer biochemical recurrence after definitive therapy: a systematic review and meta-analysis. J Urol. 2019.

  15. 15.

    Uprimny C, Kroiss AS, Decristoforo C, Fritz J, von Guggenberg E, Kendler D, et al. 68 Ga-PSMA-11 PET/CT in primary staging of prostate cancer: PSA and Gleason score predict the intensity of tracer accumulation in the primary tumour. Eur J Nucl Med Mol Imaging. 2017;44:941–9.

    CAS  PubMed  Article  Google Scholar 

  16. 16.

    Roach PJ, Francis R, Emmett L, Hsiao E, Kneebone A, Hruby G, et al. The impact of 68Ga-PSMA PET/CT on management intent in prostate cancer: results of an Australian prospective multicenter study. J Nucl Med. 2018;59:82–8.

    CAS  PubMed  Article  Google Scholar 

  17. 17.

    Kuten J, Mabjeesh NJ, Lerman H, Levine C, Barnes S, Even-Sapir E. Ga-PSMA PET/CT staging of newly diagnosed intermediate-and high-risk prostate cancer. Isr Med Assoc J. 2019;21:100–4.

    PubMed  Google Scholar 

  18. 18.

    D’amico AV, Whittington R, Malkowicz SB, Schultz D, Blank K, Broderick GA, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. Jama. 1998;280:969–74.

    PubMed  Article  Google Scholar 

  19. 19.

    Schmidkonz C, Cordes M, Goetz TI, Prante O, Kuwert T, Ritt P, et al. 68Ga-PSMA-11 PET/CT derived quantitative volumetric tumor parameters for classification and evaluation of therapeutic response of bone metastases in prostate cancer patients. Ann Nucl Med. 2019;33:766–75.

    CAS  PubMed  Article  Google Scholar 

  20. 20.

    Simsek DH, Sanli Y, Civan C, Engin MN, Isik EG, Ozkan ZG, et al. Does bone scintigraphy still have a role in the era of 68 Ga-PSMA PET/CT in prostate cancer? Ann Nucl Med. 2020

  21. 21.

    Rowe SP, Pienta KJ, Pomper MG, Gorin MA. Proposal for a structured reporting system for prostate-specific membrane antigen–targeted PET imaging: PSMA-RADS version 1.0. J Nucl Med. 2018;59:479–85.

    PubMed  PubMed Central  Article  Google Scholar 

  22. 22.

    Werner RA, Bundschuh RA, Bundschuh L, Javadi MS, Higuchi T, Weich A, et al. Molecular imaging reporting and data systems (MI-RADS): a generalizable framework for targeted radiotracers with theranostic implications. Ann Nucl Med. 2018;32:512–22.

    PubMed  PubMed Central  Article  Google Scholar 

  23. 23.

    Haran C, McBean R, Parsons R, Wong D. Five-year trends of bone scan and prostate-specific membrane antigen positron emission tomography utilization in prostate cancer: a retrospective review in a private centre. J Med Imaging Radiat Oncol. 2019.

  24. 24.

    Grubmüller B, Baltzer P, Hartenbach S, D’Andrea D, Helbich TH, Haug AR, et al. PSMA ligand PET/MRI for primary prostate cancer: staging performance and clinical impact. Clin Cancer Res. 2018;24:6300–7.

    PubMed  Article  Google Scholar 

  25. 25.

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

    PubMed  Article  Google Scholar 

  26. 26.

    Klingenberg S, Jochumsen MR, Ulhøi BP, Fredsøe J, Sørensen KD, Borre M, et al. 68Ga-PSMA PET/CT for primary NM staging of high-risk prostate cancer. J Nucl Med. 2020:jnumed. 120.245605.

  27. 27.

    Harisinghani MG, Barentsz J, Hahn PF, Deserno WM, Tabatabaei S, van de Kaa CH, et al. Noninvasive detection of clinically occult lymph-node metastases in prostate cancer. N Engl J Med. 2003;348:2491–9.

    PubMed  Article  Google Scholar 

  28. 28.

    Briganti A, Chun FK-H, Salonia A, Suardi N, Gallina A, Da Pozzo LF, et al. Complications and other surgical outcomes associated with extended pelvic lymphadenectomy in men with localized prostate cancer. Eur Urol. 2006;50:1006–13.

    PubMed  Article  Google Scholar 

  29. 29.

    Thalgott M, Düwel C, Rauscher I, Heck MM, Haller B, Gafita A, et al. One-stop-shop whole-body 68Ga-PSMA-11 PET/MRI compared with clinical nomograms for preoperative T and N staging of high-risk prostate cancer. J Nucl Med. 2018;59:1850–6.

    CAS  PubMed  Article  Google Scholar 

  30. 30.

    Mattei A, Fuechsel FG, Dhar NB, Warncke SH, Thalmann GN, Krause T, et al. The template of the primary lymphatic landing sites of the prostate should be revisited: results of a multimodality mapping study. Eur Urol. 2008;53:118–25.

    PubMed  Article  Google Scholar 

  31. 31.

    Parker CC, James ND, Brawley CD, Clarke NW, Hoyle AP, Ali A, et al. Radiotherapy to the primary tumour for newly diagnosed, metastatic prostate cancer (STAMPEDE): a randomised controlled phase 3 trial. Lancet. 2018;392:2353–66.

    PubMed  PubMed Central  Article  Google Scholar 

  32. 32.

    Sweeney C, Chen Y, Liu G, Carducci M, Jarrard D, Eisenberger M, et al. Long term efficacy and QOL data of chemohormonal therapy (C-HT) in low and high volume hormone naïve metastatic prostate cancer (PrCa): E3805 CHAARTED trial. Ann Oncol. 2016;27.

  33. 33.

    Ergül N, Günes BY, Yücetas U, Toktas MG, Çermik TF. 68Ga-PSMA-11 PET/CT in newly diagnosed prostate adenocarcinoma. Clin Nucl Med. 2018;43:e422–e7.

    PubMed  Article  Google Scholar 

  34. 34.

    Basha MAA, Hamed MAG, Hussein O, El-Diasty T, Abdelkhalek YI, Hussein YO, et al. 68 Ga-PSMA-11 PET/CT in newly diagnosed prostate cancer: diagnostic sensitivity and interobserver agreement. Abdom Radiol. 2019;1–12.

  35. 35.

    Lengana T, Lawal IO, Boshomane TG, Popoola GO, Mokoala KM, Moshokoa E, et al. 68Ga-PSMA PET/CT replacing bone scan in the initial staging of skeletal metastasis in prostate cancer: a fait accompli? Clin Genitourin Cancer. 2018;16:392–401.

    PubMed  Article  Google Scholar 

  36. 36.

    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. 2019;124:401–7.

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    Hofman MS, Lawrentschuk N, Francis RJ, Tang C, Vela I, Thomas P, et al. Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multi-centre study. Lancet. 2020.

  38. 38.

    Pyka T, Okamoto S, Dahlbender M, Tauber R, Retz M, Heck M, et al. Comparison of bone scintigraphy and 68Ga-PSMA PET for skeletal staging in prostate cancer. Eur J Nucl Med Mol Imaging. 2016;43:2114–21.

    CAS  PubMed  Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Duygu Has Simsek.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

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 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

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

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The original online version of this article was revised: The figure legends are correctly placed, however, figure images are ordered incorrectly during the publishing process. Figure 1 --> should be replaced as Figure 4 Figure 2 --> should be replaced as Figure 5 Figure 3 --> should be replaced as figure 6 Figure 4 --> should be replaced as Figure 1 Figure 5 --> should be replaced as Figure 3 Figure 6 --> should be replaced as Figure 2 The original article has been corrected.

This article is part of the Topical Collection on Oncology - Genitourinary

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Simsek, D.H., Sanli, Y., Engin, M.N. et al. Detection of metastases in newly diagnosed prostate cancer by using 68Ga-PSMA PET/CT and its relationship with modified D’Amico risk classification. Eur J Nucl Med Mol Imaging 48, 1639–1649 (2021).

Download citation


  • Prostate cancer
  • Staging
  • 68Ga-PSMA PET/CT