Purpose: To evaluate diagnostic accuracy of integrated 68Gallium labelled prostate-specific membrane antigen (68Ga-PSMA)-11 positron emission tomography (PET)/MRI in patients with primary prostate cancer (PCa) as compared to multi-parametric MRI. Material and Methods: A total of 22 patients with recently diagnosed primary PCa underwent clinically indicated 68Ga-PSMA-11 PET/CT for initial staging followed by integrated 68Ga-PSMA-11 PET/MRI. Images of multi-parametric magnetic resonance imaging (mpMRI), PET and PET/MRI were evaluated separately by applying Prostate Imaging Reporting and Data System (PIRADSv2) for mpMRI and a 5-point Likert scale for PET and PET/MRI. Results were compared with pathology reports of biopsy or resection. Statistical analyses including receiver operating characteristics analysis were performed to compare the diagnostic performance of mpMRI, PET and PET/MRI. Results: PET and integrated PET/MRI demonstrated a higher diagnostic accuracy than mpMRI (area under the curve: mpMRI: 0.679, PET and PET/MRI: 0.951). The proportion of equivocal results (PIRADS 3 and Likert 3) was considerably higher in mpMRI than in PET and PET/MRI. In a notable proportion of equivocal PIRADS results, PET led to a correct shift towards higher suspicion of malignancy and enabled correct lesion classification. Conclusion: Integrated 68Ga-PSMA-11 PET/MRI demonstrates higher diagnostic accuracy than mpMRI and is particularly valuable in tumours with equivocal results from PIRADS classification.

Keywords:
Multi-parametric magnetic resonance imaging, Prostate-specific membrane antigen, Positron emission tomography/magnetic resonance imaging, Prostate imaging reporting and data system
1.
Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A: Global cancer statistics, 2012. CA Cancer J Clin 2015; 65: 87–108.
2.
Schroder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, Kwiatkowski M, Lujan M, Lilja H, Zappa M, Denis LJ, Recker F, Berenguer A, Maattanen L, Bangma CH, Aus G, Villers A, Rebillard X, van der Kwast T, Blijenberg BG, Moss SM, de Koning HJ, Auvinen A; ERSPC Investigators: Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009; 360: 1320–1328.
3.
Lindenberg L, Ahlman M, Turkbey B, Mena E, Choyke P: Advancement of MR and PET/MR in prostate cancer. Semin Nucl Med 2016; 46: 536–543.
4.
Boesen L, Norgaard N, Logager V, Balslev I, Thomsen HS: A prospective comparison of selective multiparametric magnetic resonance imaging fusion-targeted and systematic transrectal ultrasound-guided biopsies for detecting prostate cancer in men undergoing repeated biopsies. Urol Int 2017; 99: 384–391.
5.
Weinreb JC, Barentsz JO, Choyke PL, Cornud F, Haider MA, Macura KJ, Margolis D, Schnall MD, Shtern F, Tempany CM, Thoeny HC, Verma S: PI-RADS prostate imaging – reporting and data system: 2015, version 2. Eur Urol 2016; 69: 16–40.
6.
Hoeks CM, Barentsz JO, Hambrock T, Yakar D, Somford DM, Heijmink SW, Scheenen TW, Vos PC, Huisman H, van Oort IM, Witjes JA, Heerschap A, Futterer JJ: Prostate cancer: multiparametric MR imaging for detection, localization, and staging. Radiology 2011; 261: 46–66.
7.
Barentsz JO, Richenberg J, Clements R, Choyke P, Verma S, Villeirs G, Rouviere O, Logager V, Futterer JJ; European Society of Urogenital Radiology: ESUR prostate MR guidelines 2012. Eur Radiol 2012; 22: 746–757.
8.
Borkowetz A, Platzek I, Toma M, Renner T, Herout R, Baunacke M, Laniado M, Baretton GB, Froehner M, Zastrow S, Wirth MP: Evaluation of prostate imaging reporting and data system classification in the prediction of tumor aggressiveness in targeted magnetic resonance imaging/ultrasound-fusion biopsy. Urol Int 2017; 99: 177–185.
9.
Murphy G, Haider M, Ghai S, Sreeharsha B: The expanding role of MRI in prostate cancer. AJR Am J Roentgenol 2013; 201: 1229–1238.
10.
Jadvar H: Positron emission tomography in prostate cancer: summary of systematic reviews and meta-analysis. Tomography 2015; 1: 18–22.
11.
Afshar-Oromieh A, Hetzheim H, Kratochwil C, Benesova M, Eder M, Neels OC, Eisenhut M, Kubler W, Holland-Letz T, Giesel FL, Mier W, Kopka K, Haberkorn U: The theranostic PSMA ligand PSMA-617 in the diagnosis of prostate cancer by PET/CT: biodistribution in humans, radiation dosimetry, and first evaluation of tumor lesions. J Nucl Med 2015; 56: 1697–1705.
12.
Pfob CH, Ziegler S, Graner FP, Kohner M, Schachoff S, Blechert B, Wester HJ, Scheidhauer K, Schwaiger M, Maurer T, Eiber M: Biodistribution and radiation dosimetry of (68)Ga-PSMA HBED CC-a PSMA specific probe for PET imaging of prostate cancer. Eur J Nucl Med Mol Imaging 2016; 43: 1962–1970.
13.
Herrmann K, Bluemel C, Weineisen M, Schottelius M, Wester HJ, Czernin J, Eberlein U, Beykan S, Lapa C, Riedmiller H, Krebs M, Kropf S, Schirbel A, Buck AK, Lassmann M: Biodistribution and radiation dosimetry for a probe targeting prostate-specific membrane antigen for imaging and therapy. J Nucl Med 2015; 56: 855–861.
14.
Afshar-Oromieh A, Babich JW, Kratochwil C, Giesel FL, Eisenhut M, Kopka K, Haberkorn U: The rise of PSMA ligands for diagnosis and therapy of prostate cancer. J Nucl Med 2016; 57: 79S–89S.
15.
Bostwick DG, Pacelli A, Blute M, Roche P, Murphy GP: Prostate specific membrane antigen expression in prostatic intraepithelial neoplasia and adenocarcinoma: a study of 184 cases. Cancer 1998; 82: 2256–2261.
16.
Ananias HJ, van den Heuvel MC, Helfrich W, de Jong IJ: Expression of the gastrin-releasing peptide receptor, the prostate stem cell antigen and the prostate-specific membrane antigen in lymph node and bone metastases of prostate cancer. Prostate 2009; 69: 1101–1108.
17.
Minner S, Wittmer C, Graefen M, Salomon G, Steuber T, Haese A, Huland H, Bokemeyer C, Yekebas E, Dierlamm J, Balabanov S, Kilic E, Wilczak W, Simon R, Sauter G, Schlomm T: High level PSMA expression is associated with early PSA recurrence in surgically treated prostate cancer. Prostate 2011; 71: 281–288.
18.
Maurer T, Eiber M, Schwaiger M, Gschwend JE: Current use of PSMA-PET in prostate cancer management. Nat Rev Urol 2016; 13: 226–235.
19.
Eiber M, Weirich G, Holzapfel K, Souvatzoglou M, Haller B, Rauscher I, Beer AJ, Wester HJ, Gschwend J, Schwaiger M, Maurer T: Simultaneous 68Ga-PSMA HBED-CC PET/MRI improves the localization of primary prostate cancer. Eur Urol 2016; 70: 829–836.
20.
Afshar-Oromieh A, Haberkorn U, Schlemmer HP, Fenchel M, Eder M, Eisenhut M, Hadaschik BA, Kopp-Schneider A, Rothke M: 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: 887–897.
21.
Rosenkrantz AB, Kim S, Campbell N, Gaing B, Deng FM, Taneja SS: Transition zone prostate cancer: revisiting the role of multiparametric MRI at 3 T. AJR Am J Roentgenol 2015; 204:W266–W272.
22.
Liddell H, Jyoti R, Haxhimolla HZ: mp-MRI prostate characterised PIRADS 3 lesions are associated with a low risk of clinically significant prostate cancer – a retrospective review of 92 biopsied PIRADS 3 lesions. Curr Urol 2015; 8: 96–100.
23.
De Visschere P, Pattyn E, Ost P, Claeys T, Lumen N, Villeirs G: Comparison of the prostate imaging reporting and data system (PI-RADS) version 1 and 2 in a cohort of 245 patients with histopathological reference and long-term follow-up. J Belg Soc Radiol 2016; 100.
24.
Vargas HA, Hotker AM, Goldman DA, Moskowitz CS, Gondo T, Matsumoto K, Ehdaie B, Woo S, Fine SW, Reuter VE, Sala E, Hricak H: Updated prostate imaging reporting and data system (PIRADS v2) recommendations for the detection of clinically significant prostate cancer using multiparametric MRI: critical evaluation using whole-mount pathology as standard of reference. Eur Radiol 2016; 26: 1606–1612.
25.
Reisaeter LA, Futterer JJ, Halvorsen OJ, Nygard Y, Biermann M, Andersen E, Gravdal K, Haukaas S, Monssen JA, Huisman HJ, Akslen LA, Beisland C, Rorvik J: 1.5-T multiparametric MRI using PI-RADS: a region by region analysis to localize the index-tumor of prostate cancer in patients undergoing prostatectomy. Acta Radiol 2015; 56: 500–511.
26.
Lindenberg L, Ahlman M, Turkbey B, Mena E, Choyke P: Evaluation of prostate cancer with PET/MRI. J Nucl Med 2016; 57(suppl 3):111S–116S.
27.
Piert M, Montgomery J, Kunju LP, Siddiqui J, Rogers V, Rajendiran T, Johnson TD, Shao X, Davenport MS: 18F-choline PET/MRI: the additional value of PET for MRI-guided transrectal prostate biopsies. J Nucl Med 2016; 57: 1065–1070.
28.
Freitag MT, Radtke JP, Hadaschik BA, Kopp-Schneider A, Eder M, Kopka K, Haberkorn U, Roethke M, Schlemmer HP, Afshar-Oromieh A: Comparison of hybrid (68)Ga-PSMA PET/MRI and (68)Ga-PSMA PET/CT in the evaluation of lymph node and bone metastases of prostate cancer. Eur J Nucl Med Mol Imaging 2016; 43: 70–83.
© 2018 S. Karger AG, Basel
2018
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.