De Nunzio, Cosimo

Franco, Giorgio

Guercio, Alessandro

Lombardo, Riccardo

English

Archivio della ricerca- Università di Roma La Sapienza

Re: ‘Prostate-specific membrane antigen positronemission tomography in addition to multiparametricmagnetic resonance imaging and biopsies to selectprostate cancer patients for focal therapy’We read with interest the study by Geboers et al. [1]evaluating the additional value of prostate-specific membraneantigen-positron emission tomography (PSMA-PET) toconventional diagnostic tools to select patients for hemi-ablative focal therapy (FT). The aim of the study was toevaluate the accuracy of PSMA-PET, multiparametric MRI(mpMRI) and systematic biopsies (separate and combined) toidentify prostate quadrants with clinically significant prostatecancer (csPCa) in a FT-eligible patient cohort. The studyenrolled retrospectively patients undergoing radicalprostatectomy (RP) who met the eligibility criteria for FT (PSAlevel <15 ng/mL, ≤T2b, International Society of UrologicalPathology Grade 2–3). According to their results, addingPSMA-PET to mpMRI plus biopsies improves the accuracyfrom 0.79 to 0.84 on area under the receiver operatingcharacteristic curve (AUC) analysis in the selection of patientsfor hemi-ablative FT. Moreover, addition of PSMA-PETcorrectly identified 26/46 (57%) unsuitable patients andresulted in four of 138 (3%) false-positive exclusions.Being aware of the authors’ good intention to make thetreatment for PCa increasingly minimally invasive, thusreducing side-effects associated with radical treatment andimprove quality of life, we have some concern about thefollowing points according to the current evidence [2].We believe that, although supported by statistically significantresults, the diagnostic accuracy with the addition of PSMA-PET to mpMRI and prostate biopsy in terms of the AUCdeviates from a moderately accurate level to only slightlyhigher (ranging from 0.79 to 0.84), at the expense of areduction in specificity from 83% to 80% when addingPSMA-PET. These data confirm the positions of Europeanguidelines, which define PSMA-PET as highly accurate fordisease staging but recommend against modifying the plannedtreatment based on its results. Therefore, the benefits of usingPSMA-PET for the primary diagnosis of csPCa remainuncertain in the light of current evidence, and furtherextensive research on the topic is necessary [3].The ideal candidates for hemi-ablative FT are patients withunilateral disease confined to the organ. Several studies haveevaluated the accuracy of sextant and/or extended biopsy inpredicting unilateral tumours. The rate of agreement onunilaterality of PCa between biopsy and RP specimen was<30%. In this study, 112 patients met the eligibility criteria forFT with the addition of PSMA-PET to mpMRI and biopsy.However, >20% (20/112) would not have met the criteria forFT upon final histological examination derived from RP,representing a numerically significant proportion of patients.Furthermore, at least two completely different strategy forbiopsy were included: a saturation like template (mean of 29biopsies) and a standard mean 12-cores template.Notwithstanding these limitations, the authors’ have the meritof evaluating the possible role of PSMA-PET as a diagnostictool for PCa and particularly to select best candidates for FT[2]. However, we believe that, despite the increasing claim ofPSMA-PET as a more accurate method, it suffers from excesssensitivity, and its use should be directed towards patientswith a high risk of metastatic PCa, particularly when thetraditional imaging is controversial or in doubt. [3,4]. Untilfurther studies confirm its validity in this setting, we supportthe importance to focus on improving the diagnostic accuracyof mpMRI through standardising report interpretation,incorporating artificial intelligence, and centralising theexecution of the method within high-volume hospital centres[3–5] rather than adding new possible imaging modalitieswith their own limitations.Disclosure of InterestsNone declared.Alessandro Guercio, Giorgio Franco,Riccardo Lombardoand Cosimo De NunzioDepartment of Urology, Sapienza University, Rome, ItalyReferences1 Geboers B, Meijer D, Counter W et al. Prostate-specific membraneantigen positron emission tomography in addition to multiparametricmagnetic resonance imaging and biopsies to select prostate cancerpatients for focal therapy. BJU Int 2023. In press. https://doi.org/10.1111/bju.16207. Accessed November 20232 Bodar YJL, Boeve LMS, van Leeuwen PJ et al. Using prostate-specificmembrane antigen positron-emission tomography to guide prostate biopsiesand stage men at high-risk of prostate cancer. BJU Int 2023; 132: 705–123 Tian A, Lin R, Yu J et al. The differential diagnostic value of dual-phase18F-DCFPyL PET/CT in prostate carcinoma. Prostate Cancer Prostatic Dis2022; 25: 351–8 2023 BJU International.Published by John Wiley & Sons Ltd. www.bjui.org wileyonlinelibrary.comBJU Int 2024 doi:10.1111/bju.16263Letter to the Editor4 De Nunzio C, Amstrong AJ, Van Oort I, Dorff T. Editor’ summary: aparadigm shift in castration-resistant prostate cancer management. ProstateCancer Prostatic Dis 2022; 25: 601–35 Albisinni S, Sarkis J, Diamand R, De Nunzio C. Prebiopsy 68Ga-PSMAPET imaging: can we improve the current diagnostic pathway for prostatecancer? Prostate Cancer Prostatic Dis 2023; 26: 47–9Correspondence: Riccardo Lombardo, Department ofUrology, Sapienza University of Rome, Italy.e-mail: rlombardo@me.comAbbreviations: AUC, area under the receiver operatingcharacteristic curve; FT, focal therapy; mpMRI,multiparametric MRI; (cs)PCa, (clinically significant) prostatecancer; PET, positron emission tomography; PSMA, prostate-specific membrane antigen; RP, radical prostatectomy.2  2023 BJU International.Letter to the Editor 1464410x, 0, Downloaded from https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/bju.16263 by University Di Roma La Sapienza, Wiley Online Library on [17/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

Re: 'Prostate-specific membrane antigen positron emission tomography in addition to multiparametric magnetic resonance imaging and biopsies to select prostate cancer patients for focal therapy'

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Re: 'Prostate-specific membrane antigen positron emission tomography in addition to multiparametric magnetic resonance imaging and biopsies to select prostate cancer patients for focal therapy'

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