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Islam R, Desai S, Moran M, Golombos DM. The Role of PSMA PET Imaging in Prostate Cancer: Current Applications and Future Directions. Curr Urol Rep 2025; 26:46. [PMID: 40448740 DOI: 10.1007/s11934-025-01268-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2025] [Indexed: 06/02/2025]
Abstract
PURPOSE OF REVIEW Prostate-specific membrane antigen (PSMA)-targeted positron emission tomography (PET) imaging has revolutionized prostate cancer detection and management. This review aims to evaluate the latest advancements in PSMA PET imaging, assess its clinical applications in various disease stages, and compare it to conventional imaging techniques. We sought to determine how PSMA PET impacts clinical decision-making, treatment strategies, and patient outcomes, with a focus on its expanding role in precision oncology. RECENT FINDINGS Recent studies have demonstrated that PSMA PET exhibits superior sensitivity and specificity in detecting prostate cancer metastases, particularly in cases of biochemical recurrence and early-stage disease. The advent of radiolabeled PSMA ligands, such as 68Ga-PSMA-11 and 18 F-DCFPyL, has led to improved diagnostic accuracy. Furthermore, PSMA-targeted radioligand therapies (e.g., 177Lu-PSMA-617) show promising results in metastatic castration-resistant prostate cancer (mCRPC), offering a novel therapeutic avenue. Studies have also highlighted the role of PSMA PET in refining treatment plans, including guiding surgery and radiotherapy. PSMA PET imaging represents a paradigm shift in prostate cancer diagnostics, staging, and treatment monitoring. It has led to earlier and more accurate detection of metastases, significantly altering management strategies. The growing body of evidence supports its integration into standard-of-care protocols, with ongoing research focusing on optimizing its therapeutic applications. Future studies should explore cost-effectiveness, accessibility, and potential synergies with emerging systemic therapies to further enhance patient outcomes.
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Affiliation(s)
- Raeesa Islam
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, 285 George St. Apt 906, New Brunswick, NJ, USA.
| | - Shrijal Desai
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Melissa Moran
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, 285 George St. Apt 906, New Brunswick, NJ, USA
| | - David M Golombos
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, 285 George St. Apt 906, New Brunswick, NJ, USA
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Esfahani SA, Morris MJ, Sartor O, Frydenberg M, Fanti S, Calais J, Vapiwala N. Standardized template for clinical reporting of PSMA PET/CT scans. Eur J Nucl Med Mol Imaging 2024; 52:335-341. [PMID: 39143250 PMCID: PMC11599343 DOI: 10.1007/s00259-024-06857-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 07/21/2024] [Indexed: 08/16/2024]
Abstract
PURPOSE Accurate diagnosis and staging of prostate cancer are crucial to improving patient care. Prostate-specific membrane antigen (PSMA)-targeted positron emission tomography with computed tomography (PET/CT) imaging has demonstrated superiority for initial staging and restaging in patients with prostate cancer. Referring physicians and PET/CT readers must agree on a consistent communication method and application of information derived from this imaging modality. While several guidelines have been published, a single PSMA PET/CT reporting template has yet to be widely adopted. Based on the consensus from community and academic physicians, we developed a standardized PSMA PET/CT reporting template for radiologists and nuclear medicine physicians to report and relay key imaging findings to referring physicians. The aim was to improve the quality, clarity, and utility of imaging results reporting to facilitate patient management decisions. METHODS Based on community and expert consensus, we developed a standardized PSMA PET/CT reporting template to deliver key imaging findings to referring clinicians. RESULTS Core category components proposed include a summary of any prior treatment history; presence, location, and degree of PSMA radiopharmaceutical uptake in primary and/or metastatic tumor(s), lesions with no uptake, and incidentally found lesions with positive uptake on PET/CT. CONCLUSIONS This article provides recommendations on best practices for standardized reporting of PSMA PET/CT imaging. The generated reporting template is a proposed supplement designed to educate and improve data communication between imaging experts and referring physicians.
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Affiliation(s)
- Shadi A Esfahani
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Michael J Morris
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oliver Sartor
- Department of Medical Oncology, Mayo Clinic, Minnesota, USA
| | - Mark Frydenberg
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Cabrini Institute, Cabrini Health, Malvern, Australia
| | - Stefano Fanti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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Alexoff D, Choi SR, Ploessl K, Kim D, Zhao R, Zhu L, Kung H. Optimization and scale up of production of the PSMA imaging agent [ 18F]AlF-P16-093 on a custom automated radiosynthesis platform. EJNMMI Radiopharm Chem 2024; 9:15. [PMID: 38393404 PMCID: PMC10891009 DOI: 10.1186/s41181-024-00247-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/20/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Recent advancements in positron emission tomograph (PET) using prostate specific membrane antigen (PSMA)-targeted radiopharmaceuticals have changed the standard of care for prostate cancer patients by providing more accurate information during staging of primary and recurrent disease. [68Ga]Ga-P16-093 is a new PSMA-PET radiopharmaceutical that demonstrated superior imaging performance in recent head-to-head studies with [68Ga]Ga-PSMA-11. To improve the availability of this new PSMA PET imaging agent, [18F]AlF-P16-093 was developed. The 18F-analog [18F]AlF-P16-093 has been synthesized manually at low activity levels using [18F]AlF2+ and validated in pre-clinical models. This work reports the optimization of the production of > 15 GBq of [18F]AlF-P16-093 using a custom automated synthesis platform. RESULTS The sensitivity of the radiochemical yield of [18F]AlF-P16-093 to reaction parameters of time, temperature and reagent amounts was investigated using a custom automated system. The automated system is a low-cost, cassette-based system designed for 1-pot syntheses with flow-controlled solid phase extraction (SPE) workup and is based on the Raspberry Pi Zero 2 microcomputer/Python3 ecosystem. The optimized none-decay-corrected yield was 52 ± 4% (N = 3; 17.5 ± 2.2 GBq) with a molar activity of 109 ± 14 GBq/µmole and a radiochemical purity of 98.6 ± 0.6%. Run time was 30 min. A two-step sequence was used: SPE-purified [18F]F- was reacted with 80 nmoles of freeze-dried AlCl3·6H2O at 65 °C for 5 min followed by reaction with 160 nmoles of P16-093 ligand at 40 °C for 4 min in a 1:1 mixture of ethanol:0.5 M pH 4.5 NaOAc buffer. The mixture was purified by SPE (> 97% recovery). The final product formulation (5 mM pH 7 phosphate buffer with saline) exhibited a rate of decline in radiochemical purity of ~ 1.4%/h which was slowed to ~ 0.4%/h when stored at 4 °C. CONCLUSION The optimized method using a custom automated system enabled the efficient (> 50% none-decay-corrected yield) production of [18F]AlF-P16-093 with high radiochemical purity (> 95%). The method and automation system are simple and robust, facilitating further clinical studies with [18F]AlF-P16-093.
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Affiliation(s)
- David Alexoff
- Five Eleven Pharma Inc., Philadelphia, PA, 19104, USA.
| | - Seok Rye Choi
- Five Eleven Pharma Inc., Philadelphia, PA, 19104, USA
| | - Karl Ploessl
- Five Eleven Pharma Inc., Philadelphia, PA, 19104, USA
| | - Dohyun Kim
- Isotope Research and Production Department, Brookhaven National Laboratory, Upton, NY, 11973, USA
| | - Ruiyue Zhao
- Department of Nuclear Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, China
| | - Lin Zhu
- College of Chemistry, Key Laboratory of Radiopharmaceuticals, Ministry of Education, Beijing Normal University, Beijing, 100875, China
| | - Hank Kung
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Mandel A, Das C, Ting R, Kaufmann B, Tewari A. Intraoperative Fluorescent Image Guidance for Nerve-Sparing Prostatectomy: A Review of Historical Context and Current Research. J Endourol 2024; 38:30-39. [PMID: 37850492 DOI: 10.1089/end.2023.0480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023] Open
Abstract
Fluorescent probes in the near-infrared (NIR) range have immense potential to improve observation of positive margins, lymph nodes, and nerves in prostatectomy. Development of fluorescent dyes and mechanisms of cellular uptake paved the way for the current emerging technologies. However, intracellular transport of fluorophores proved to be logistically challenging with respect to intraoperative deployment. Peptide-based probes with high specificity for nerves enabled broader and more rapid labeling. Key features of the ideal probe include selectivity, minimal background noise, safety, and low cost. Human neuropeptide 401 (HNP401) and oxazine-based probes perform well in these categories. As for tumor-specific labeling, prostate specific membrane antigen is relatively selective for the prostate and can be conjugated to a fluorophore. NIR spectrum emission is an ideal range for clinical imaging use, as fluorescence occurs outside the field of visible light, and tissue optical properties diverge significantly at the visible-NIR transition. Indocyanine, carbocyanine, and fluorescein derivatives are common fluorophore conjugates for the probes. Finally, to harness the power of fluorescence intraoperatively, the surgeon must look through a specialized lens. Multiphoton microscopy, optical coherence tomography, and confocal laser endomicroscopy have emerged as frontrunners in this arena. As with any evolving technology, ongoing research is expanding the applications of fluorescent intraoperative imaging in prostate surgery. Innovations in camera technology, dye selection, and image processing are refining the technique's capabilities. A core challenge of these technologies translating into the operating room relates to size and the ability to view objects at vastly different magnifications. Dual modality zoom settings are promising solutions. Furthermore, interdisciplinary collaboration between surgeons, imaging specialists, and researchers continues to drive advancements. In conclusion, fluorescent intraoperative imaging has the potential to usher in a new era of precision and safety in prostate surgery.
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Affiliation(s)
- Asher Mandel
- The Milton and Carroll Petrie Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chandan Das
- The Milton and Carroll Petrie Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Basil Kaufmann
- The Milton and Carroll Petrie Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Ashutosh Tewari
- The Milton and Carroll Petrie Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Wang G, Li L, Zhu M, Zang J, Wang J, Wang R, Yan W, Zhu L, Kung HF, Zhu Z. A prospective head-to-head comparison of [ 68Ga]Ga-P16-093 and [ 68Ga]Ga-PSMA-11 PET/CT in patients with primary prostate cancer. Eur J Nucl Med Mol Imaging 2023; 50:3126-3136. [PMID: 37233785 PMCID: PMC10213584 DOI: 10.1007/s00259-023-06283-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/19/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE We aimed to compare the diagnostic performance and biodistribution of two similar PET agents, [68Ga]Ga-P16-093 and [68Ga]Ga-PSMA-11, in the same group of primary prostate cancer (PCa) patients. METHODS Fifty patients with untreated, histologically confirmed PCa by needle biopsy were enrolled. Each patient underwent [68Ga]Ga-P16-093 and [68Ga]Ga-PSMA-11 PET/CT within a week. In addition to visual analysis, the standardized uptake value (SUV) was measured for semiquantitative comparison and correlation analysis. RESULTS [68Ga]Ga-P16-093 PET/CT detected more positive tumors than [68Ga]Ga-PSMA-11 PET/CT (202 vs. 190, P = 0.002), both for intraprostatic lesions (48 vs. 41, P = 0.016) and metastatic lesions (154 vs. 149, P = 0.125), especially for intraprostatic lesions in low- and intermediate-risk PCa patients (21/23 vs. 15/23, P = 0.031). Furthermore, [68Ga]Ga-P16-093 PET/CT exhibited a significantly higher SUVmax for most matched tumors (13.7 ± 10.2 vs. 11.4 ± 8.3, P < 0.001). For normal organs, [68Ga]Ga-P16-093 PET/CT showed significantly lower activity in the kidney (SUVmean: 20.1 ± 6.1 vs. 29.3 ± 9.1, P < 0.001) and urinary bladder (SUVmean: 6.5 ± 7.1 vs. 20.9 ± 17.4, P < 0.001), but displayed a higher uptake in the parotid gland (SUVmean: 8.7 ± 2.6 vs. 7.6 ± 2.1, P < 0.001), liver (SUVmean: 7.0 ± 1.9 vs. 3.7 ± 1.3, P < 0.001), and spleen (SUVmean: 8.2 ± 3.0 vs. 5.2 ± 2.2, P < 0.001) than [68Ga]Ga-PSMA-11 PET/CT. CONCLUSION [68Ga]Ga-P16-093 PET/CT demonstrated higher tumor uptake and better tumor detectability than [68Ga]Ga-PSMA-11 PET/CT, especially in low- and intermediate-risk PCa patients, which indicated that [68Ga]Ga-P16-093 may serve as an alternative agent for detection of PCa. TRIAL REGISTRATION 68Ga-P16-093 and 68Ga-PSMA-11 PET/CT Imaging in the Same Group of Primary Prostate Cancer Patients (NCT05324332, Registered 12 April 2022, retrospectively registered). URL OF REGISTRY: https://clinicaltrials.gov/ct2/show/NCT05324332 .
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Affiliation(s)
- Guochang Wang
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China
| | - Linlin Li
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China
| | - Ming Zhu
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China
| | - Jie Zang
- Department of Nuclear Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Jiarou Wang
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China
| | - Rongxi Wang
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China
| | - Weigang Yan
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China.
| | - Lin Zhu
- College of Chemistry, Key Laboratory of Radiopharmaceuticals, Ministry of Education, Beijing Normal University, Beijing, 100875, China.
| | - Hank F Kung
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Zhaohui Zhu
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China.
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Stangl-Kremser J, Patel N, Hu JC. Intermediate Grade Prostate Cancer and Risk for Adverse Pathology Radical Prostatectomy: Implications for Partial Gland Ablation Case Selection. Clin Genitourin Cancer 2023:S1558-7673(23)00096-4. [PMID: 37246010 DOI: 10.1016/j.clgc.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/16/2023] [Accepted: 04/17/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE Using nationally representative data, we determined the likelihood of adverse pathology at radical prostatectomy (RP) to better inform case selection for partial gland ablation (PGA). MATERIALS AND METHODS We identified men with clinically localized GG2 (n = 106,048) and GG3 (n = 55,488) prostate cancer on biopsy from 2010 through 2019 who subsequently underwent RP. Men with GG2 were stratified as unfavorable and favorable per NCCN guidelines. RP adverse pathology was defined as upgrading to GG4-5, pT3-4, or nodal involvement (pN1), respectively. Logistic regression determined factors associated with adverse pathology, and the Cochran-Armitage Test was used to evaluate temporal trends. RESULTS Men with biopsy GG3 vs. GG2 experienced significant upgrading (11.3% vs. 3.6%, P < .001), more EPE (26.9% vs. 21.1%), SVI (11.9% vs. 5.3%), and pN1 (4.3% vs. 1.6%), all P < .001. When comparing unfavorable vs. favorable GG2, men experienced more EPE (25.3% vs. 16.5%), SVI (7.2% vs. 3%), and pN1 (2.2% vs. 0.8%), all P < .001. In adjusted analysis, age, Hispanic race, PSA > 10 ng/mL, and ≥ 50% positive biopsy cores were associated with adverse pathology (all P < .001). The likelihood of RP adverse pathology for men with biopsy GG3 increased significantly during the study period from 38.8% in 2010 to 47.3% in 2019 (P < .001). CONCLUSION Approximately 40% of men with GG3 and more than 30% with unfavorable GG2 prostate cancer harbor adverse pathology that may not be curable by PGA. Given MRI often understages prostate cancer, our findings have significant implications for optimizing PGA case selection and cancer control outcomes.
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Affiliation(s)
| | - Neal Patel
- Department of Urology, Weill Cornell Medicine, New York, NY
| | - Jim C Hu
- Department of Urology, Weill Cornell Medicine, New York, NY.
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