Incremental Impact of [68 Ga]Ga-PSMA-11 PET/CT in Primary N and M Staging of Prostate Cancer Prior to Curative-Intent Surgery: a Prospective Clinical Trial in Comparison with mpMRI

Purpose The main objective of this prospective study was to assess the value of gallium-68 prostate-specific membrane antigen ([68 Ga]Ga-PSMA-11) positron emission tomography/computed tomography (PET/CT) in primary N and M staging of intermediate- and high-risk prostate cancer (PCa) patients before planned curative-intent radical prostatectomy (RPE) and extended pelvic lymph node dissection (ePLND). The second objective was to compare the [68 Ga]Ga-PSMA-11 PET/CT findings with standard of care pelvic multi-parametric magnetic resonance imaging (mpMRI) in the detection of locoregional lymph node metastases and intraprostatic prostate cancer. Procedures A total of 81 patients (mean age: 64.5 years, baseline mean trigger PSA (tPSA) 15.4 ng/ml, ± 15.9) with biopsy proven PCa (24 intermediate- and 57 high risk) scheduled for RPE and ePLND were enrolled in this prospective study. In 52 patients [68 Ga]Ga-PSMA-11 PET/CT, pelvic mpMRI, and RPE with ePLND have been performed. Clinical risk stratification and related biomarkers as well as Gleason score (GS) were recorded. The location of the index lesion (IL) was documented systematically for each modality using a standardized segmentation of the prostate in six segments. Distant bone and lymph node metastasis detected by [68 Ga]Ga-PSMA-11 PET/CT were documented. [68 Ga]Ga-PSMA-11 PET/CT findings were correlated with results of mpMRI and histopathology. A consensus of imaging, clinical and/or follow-up findings were used for determining the distant metastases, which were not verified by histopathology. Results In the patient cohort who underwent RPE, [68 Ga]Ga-PSMA-11 PET/CT and mpMRI detected the IL in 86.5% and 98.1% of the patients, respectively. The median of the maximum standardized uptake value (SUVmax) in the intraprostatic IL was 12 (range, 4.7–67.8). Intraprostatic IL of the high-risk patients showed significantly higher SUVmax than those in patients with intermediate risk for distant metastases (n = 48; median: 17.84 vs. 8.77; p = 0.02). In total 729 LN were removed by ePLND in 48 patients. The histopathology verified 26 pelvic lymph node metastases (pLNM) in 20.8% (10/48) of the patients, which have been correctly identified in 60% of the patients on [68 Ga]Ga-PSMA-11 PET/CT, and in 50% on mpMRI. All but one pLNM had a maximum diameter below 10 mm. Bone metastases (BM) and distant LNM (dLNM) were found in 17.3% of the patients on [68 Ga]Ga-PSMA-11 PET/CT imaging. 39.0% of the [68 Ga]Ga-PSMA-11 PET-positive BM showed no suspicious morphological correlation on CT. Conclusion [68 Ga]Ga-PSMA-11 PET/CT shows high diagnostic performance for N and M staging of patients with intermediate- and high-risk prostate cancer and seems to be superior to pelvic mpMRI in the detection of locoregional lymph node metastases. A significant correlation was found between SUVmax of the intraprostatic index lesion and risk stratification based on tPSA level and GS. The results of this study emphasize again on the role of metabolic molecular imaging using specific tracers in selected patients, leading to tailored therapy approach. Supplementary Information The online version contains supplementary material available at 10.1007/s11307-021-01650-9.

In total 729 LN were removed by ePLND in 48 patients. The histopathology verified 26 pelvic lymph node metastases (pLNM) in 20.8% (10/48) of the patients, which have been correctly identified in 60% of the patients on [ 68 Ga]Ga-PSMA-11 PET/CT, and in 50% on mpMRI. All but one pLNM had a maximum diameter below 10 mm. Bone metastases (BM) and distant LNM (dLNM) were found in 17.3% of the patients on [ 68 Ga] Ga-PSMA-11 PET/CT imaging. 39.0% of the [ 68 Ga]Ga-PSMA-11 PET-positive BM showed no suspicious morphological correlation on CT.

Introduction
Prostate cancer (PCa) is the second most common malignancy in men worldwide and the most diagnosed cancer in most European countries [1]. Therefore, the selection of the most suitable diagnostic pathway for accurate staging of the disease plays a pivotal role in management of the PCa patients guiding to the appropriate treatment approach [2]. To date, there is no recommendation on the use of Galliumlabeled prostate-specific membrane antigen positron emission tomography-computed tomography ([ 68 Ga]Ga-PSMA-11 PET/CT) imaging for primary staging of PCa in the current EAU-ESTRO-SIOG Guidelines [3]. However, multiparametric magnetic resonance imaging (mpMRI) is recommended for local staging in patients with intermediate-and high-risk PCa. For the assessment of distant metastases, cross-sectional abdomen-pelvic imaging by computed tomography (CT) and/ or bone scan are recommended [3,4]. Prostate-specific membrane antigen (PSMA) is a type II transmembrane protein that is expressed on the cell surface of prostatic cells, but also in the neovasculature of other malignant neoplasms [5]. It is overexpressed up to 1000 times in PCa cells compared to normal prostate epithelial cells [6]. This biological characteristics enables excellent depiction of the PCa cells by [ 68 Ga] Ga-PSMA-11 PET/CT imaging [7,8]. It has also been shown that there is a positive correlation between PSMA expression and Gleason score (GS). Moreover, a high PSMA expression is significantly associated with a higher risk of disease recurrence following curative surgery [9]. In recent years, several studies assessed the potential of radiolabeled-PSMA-11 PET/ CT in PCa; however, the main focus was on patients with biochemical recurrence [10][11][12]. There are far less studies comparing the diagnostic value between [ 68 Ga]Ga-PSMA-11 PET/CT and mpMRI in the staging setting, particularly in the assessment of pelvic lymph nodes. In addition, most of previous investigations presented retrospective data [13][14][15][16][17][18].
To the best of our knowledge, there are only few studies in this concern with prospective design [19].
Considering the limitations addressed in the previous studies, mainly retrospective design without histopathologic correlations and clear standard of proof, we performed this prospective clinical trial to assess the value of [ 68 Ga]Ga-PSMA-11 PET/CT in pre-operative N and M staging of intermediate-and high-risk PCa patients compared to pelvic multi-parametric magnetic resonance imaging (mpMRI) and histopathological findings. Furthermore, we investigated the agreement between [ 68 Ga]Ga-PSMA-11 PET/CT and mpMRI in the detection of the intraprostatic index lesion (IL) and assessed the impact of clinical biomarkers on [ 68 Ga]Ga-PSMA-11 PET-positivity.

Patients and Methods
This prospective single-center study was performed in accordance with the principles of the 1964 Declaration of Helsinki and its later amendments or comparable standards and approved by the routing ethics committee of the province with trial number of "415-E/2146/4-2017" and was registered in the European Clinical Trials Database (EudraCT number: 2020-000,771-20). Written informed consent was obtained from all individuals participated in the study according to the guidelines of the Ethics Committee.
All included patients were scheduled for [ 68 Ga]Ga-PSMA-11 PET/CT, pelvic mpMRI, and radical prostatectomy (RPE). Trigger PSA (tPSA), Gleason score (GS), and National Comprehensive Cancer Network (NCCN) risk stratification based on biopsy were recorded. The final diagnosis was principally based on histopathological sections from RPE. In case of lack of histopathology, undetermined findings, or disagreement between two readers, the final interpretation has been defined by an interdisciplinary consensus using other imaging modalities and clinical findings.

Patients
Overall, 81 consecutive patients (mean age 64.5 years, 45.3-79.1/mean tPSA 15.4 ng/ml; range, 4.1-94.0) have been prospectively included between September 2017 and January 2020. The inclusion criteria were transrectal ultrasound (TRUS)-guided biopsy-proven prostate cancer, without any clinical evidence of metastases and a median Eastern Cooperative Oncology Group (ECOG) performance status of zero, who were principally scheduled for RPE. The criteria for patient selection are shown in Table 1.

Image Acquisition [ 68 Ga]Ga-PSMA-11 PET/CT
Imaging was performed systematically according to the study protocol from the base of skull to the proximal femur (PET-Position 2 min 40 s, 2 mm slices) using two different PET/CT scanners (Philips Ingenuity TF, Amsterdam/the Netherlands, and Siemens Biograph mCT, Erlangen/Germany). Mean interval between [ 68 Ga]Ga-PSMA-11 application and the start of the acquisition was 60 min (SD ± 14.4 min). The mean injected activity per kg/bodyweight was 2.15 MBq. A noncontrast-enhanced low-dose CT scan (Siemens: Care Dose 4D, Care kV, slice thickness 1.2 mm and pitch 1.5; Philips: 100 kV, 33 mAs, slice thickness 1.5 mm and pitch 0.8) was performed for attenuation correction and localization. Slices measuring 3 mm were reconstructed using iDose mode level 3 (Philips Ingenuity TF), respectively, SAFIRE level 3 (Siemens Biograph). Both PET/CT scanners are EARL/EANM (EANM Research Ltd/European Association of Nuclear Medicine) accredited. Therefore, we assume that the performance of both scanners is almost similar. PSMA-11 (Glu-NH-CO-NH-Lys(Ahx)-HBED-CC) form ABX advanced biochemical compounds (Radeberg, Germany) was synthesized using the SCINTOMICS GRP ® module. The used procedure follows the manufacturer's information (version 2.0). Several quality checks were performed including thin-layer chromatography (TLC) and high-performance liquid chromatography (HPLC) to guarantee a radiochemical purity > 95 %.

Multiparametric MRI
The mpMRI images were performed covering the pelvis using a 3 Tesla MRI (Achieva, Philips Medical Systems, Best/the Netherlands) with an anterior coil. Patient position was "feet first," and a pelvis compression belt was used. The MRI exam was performed and interpreted in accordance with the current Prostate Imaging Reporting and Data System version 2 guidelines (PI-RADS v 2.0) [20]. T2-weighted turbo spin-echo (3 mm sagittal, transversal and coronary slices) and transversal diffusion-weighted (DWI) sequences, including high b-value images (0/50/1000/2000s/mm 2 ), were acquired. After injection of 1 ml per bodyweight contrast media gadobutrol (Gadovist, Bayer Healthcare, Germany) dynamic T1-weighted fast field echo and post-contrast T1-weighted images were obtained, the FOV was focused on the prostate. In addition, DWI images (b-value images 0/800/1200 s/mm 2 ) and transversal post-contrast DIXON-W T1-weighted images with a larger FOV for pelvic lymph node evaluation and covering the entire pelvis were performed.

Image interpretation [ 68 Ga]Ga-PSMA-11 PET/CT
Reporting was done systematically using a segmentation of the prostate in six segments (left and right -base, mid, apex) for [ 68 Ga]Ga-PSMA-11 PET/CT. An increased, nonphysiologic uptake more than background activity in each organ (e.g., prostate, bone) or more than blood pool (e.g., lymph nodes) was considered as abnormal. Images were evaluated by two board-certified nuclear medicine physicians (L.R. and G.S-Z.) who were aware of all available clinical data, but blinded to the localization of the primary tumor as known from the transrectal ultrasound (TRUS)-guided biopsy. Lesion-based mean and maximum standardized uptake value (SUVmean/max) were measured using a 40 % threshold of maximum activity in the 3D volume of interest (VOI) by using the commercially available image viewing software IntelliSpace Portal (Koninklijke Philips N.V., 2015). The lesion with the highest SUVmax was defined as "index lesion" (IL). Number and position of lymph nodes and bone lesions with abnormal increased uptake have been documented.

Multiparametric MRI
All images were evaluated by an experienced board-certified uro-radiologist (M.M.), using the PI-RADS v2-scoring system [20], who was aware of all available clinical data, but was blinded to the location of the primary tumor as known from the TRUS biopsy and the PET/CT images. A second experienced uro-radiologist (R.F.) has supervised the reading especially in undetermined cases. The lesion with the highest PIRADS classification was defined as IL. If there were more lesions with the same PIRADS classification, the lesion with the lager diameter was defined as IL.

Correlation of Intraprostatic Imaging Findings with Histopathology
For an inter-modality comparison of the anatomic location of the intraprostatic lesions, the 6-segment model (left and right -base, mid, apex) was used for each modality. RPE specimen were routinely grossly dissected with clearly defined localization and diagnosed including the GS according to the College of American Pathologists (CAP) guidelines. Prostate tissue was evaluated histologically, and hematoxylin-eosin stained tissue sections were analyzed. For the categorization of imaging findings, a histological tumor burden of more than 60 % of malignant cells in the respective section in one of the six segments was defined as positive. Histopathological evaluation was done by an experienced board-certified pathologist (C.H-K.).

Statistical Analysis
Data were crosschecked for consistency and normality. Data were visually inspected for invalid values and outliers by using probability plots and Kolmogorov-Smirnov test was applied to test for normality. In case of non-normal data, Kruskal-Wallis ANOVA and Mann-Whitney U test were applied to compare medians among various independent groups, and Spearman correlation coefficients were used to analyze the correlations between various continuously distributed variables such as SUVmax and tPSA level. The correlation between SUVmax and GS based on biopsy and/or histopathology after prostatectomy, respectively, was assessed by Kruskal-Wallis ANOVA. The median SUVmax in the IL was 12 (range, 4.7-67.8). Only a weak correlation (n = 72, r s = 0.38, p = 0.001) was found between the SUVmax and tPSA level (Fig. 1). The difference in the SUVmax according to the particular GS was not statistically significant, neither for GS based on biopsy A significant difference was found in maximum SUV levels of the intraprostatic index lesion between intermediate compared to high-risk patients based on tPSA and GS obtained from histopathology (n = 48, median: 8.77 vs. 17.84; 25-75 % quartile: 6.41-18.55 vs. 9.98-24.24; Mann-Whitney U test: p = 0.02) (Fig. 2). However, there were no statistically significant differences in median SUVmax between tumors with T-stage pT2c and ≥ pT3a (n = 48, p = 0.098) and between tumors with Union Internationale Contre le Cancer (UICC) stadium ≤ 2 and ≥ 3 (n = 48, p = 0.056), respectively. Comparison of median SUVmax values in patients with T-stage pT2c and ≥ pT3a is shown in the supplemental Fig. 3 (see ESM 4).

LNM (N-Stage)
In total 729 LN were removed by ePLND in 48 patients, and in 20.
Overall, [ 68 Ga]Ga-PSMA-11 PET/CT was able to detect distant metastases in 17.3 % (14/81) of the patients. , which led to tailored treatment strategy for each individual and optimal management of the disease. In the detection of primary intraprostatic PCa, mpMRI showed higher sensitivity of 98.6 % comparing to 88.9 % for [ 68 Ga]Ga-PSMA-11 PET/ CT. Although, some studies found no difference between [ 68 Ga]Ga-PSMA-11 PET/CT and MRI in the detection of intraprostatic index lesions; however, similar to our findings, it is generally accepted that mpMRI is superior to [ 68 Ga] Ga-PSMA PET/CT in the assessment of the primary tumor (T-stage) [3,22,23].

Discussion
In the detection of pelvic LNM, [ 68 Ga]Ga-PSMA-11 PET/ CT showed higher sensitivity comparing to mpMRI (Fig. 3). In a previous study, Franklin et   PSA value and GS are well-accepted markers for risk stratification guiding the use of further diagnostic tools. Notably, our results suggest that the median tPSA alone seems not to be an accurate marker for selecting patients who may benefit from [ 68 Ga]Ga-PSMA-11 PET/CT, since nine patients with tPSA levels below 10 ng/ml had already LN or bone metastases. Nevertheless, our data showed a significant correlation between occurrence of distant metastases and mpMRI-based T-stage and tPSA, which could serve as clinical predictors of bone metastases on [ 68 Ga]Ga-PSMA-11 PET/CT. Also, a previous study reported that extra-prostatic disease is predictive of a poor surgical response (SR) to RPE and [ 68 Ga] Ga-PSMA-11 PET/CT had a superior predictive value for SR than GS, tPSA, or T-stage [29].
However, due to limited sample size, creating a prediction model for analysis of risk-stratification of extra-prostatic metastases was not possible. Recent studies reported various results concerning the correlation between SUVmax and PSA value [30][31][32]. We found a significant correlation between tPSA and SUVmax in the IL confirming the findings of Cytawa et al. [32] who reported weak correlation between SUVmax of primary tumors and tPSA levels. In addition, we found no association between SUVmax and GS. Using a risk assessment including histopathology-based GS and tPSA value, we found a significant difference between SUVmax levels in the IL in intermediate compared to high-risk patients. Generally, histopathology relies on a threshold for tumor cell invasion in the respective segment. In our study, a 60 % threshold was used to outline the primary tumor. Few studies reported the respective thresholds applied, and this might therefore explain controversial results concerning the relation between the intensity of [ 68 Ga]Ga-PSMA-11 uptake in the primary tumor and GS (rPearson = 0.66; p < 0.001) [31,33].
This study has some limitations. Bone metastases and distant LNM could not be histologically verified. We employed a CT protocol without contrast agent, which reduces the sensitivity in detecting lymph nodes based on the CT criteria only. However, all but one LNM were smaller than 10 mm. Although we have tried to mark dissected lymph nodes and correlate them with corresponding imaging findings, a 1:1 verification was not possible. This was mainly due to the reason that only the region of resected lymph nodes will be documented by the urologists. Thus, they were not able to mark each single LN that has been detected on imaging modalities. The comparison between [ 68 Ga]Ga-PSMA-11 PET/CT and mpMRI performance was restricted to the pelvic region due to the limited mpMRI-FOV.

Conclusions
[ 68 Ga]Ga-PSMA-11 PET/CT shows high diagnostic performance for N and M staging of patients with intermediate-and high-risk prostate cancer and seems to be superior to pelvic mpMRI in the detection of locoregional lymph node metastases. A significant correlation was found between SUVmax of the intraprostatic index lesion and risk stratification based on tPSA level and GS. The results of this study emphasize again on the role of metabolic molecular imaging using specific tracers in selected patients, leading to tailored therapy approach.
Acknowledgements We acknowledge the staff of the departments of Nuclear Medicine and Endocrinology and Radiology, of the Paracelsus Medical University in Salzburg and the patients who participated in the study. We particularly thank Dr. Lukas Rettenbacher and Dr. Sumaiya Al Siyabi, for their excellent clinical feedbacks.
Funding Open access funding provided by Paracelsus Medical University.

Consent to Participate and Publication
All patients gave written informed consent to participate in the study. All patients provided informed consent to allow for the publication of their anonymized data collected during this study.

Conflict of Interest
The authors declare that they have no conflict of interest.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.