Pieter J L De Visschere1, Chloë Standaert2, Jurgen J Fütterer3, Geert M Villeirs2, Valeria Panebianco4, Jochen Walz5, Tobias Maurer6, Boris A Hadaschik7, Frédéric E Lecouvet8, Gianluca Giannarini9, Stefano Fanti10. 1. Department of Radiology and Nuclear Medicine, Ghent University Hospital, Ghent, Belgium. Electronic address: Pieter.devisschere@ugent.be. 2. Department of Radiology and Nuclear Medicine, Ghent University Hospital, Ghent, Belgium. 3. Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. 4. Department of Radiology, Oncology and Pathology, Sapienza University of Rome, Rome, Italy. 5. Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France. 6. Department of Urology, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany; Martini-Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. 7. Department of Urology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany. 8. Department of Radiology and Medical Imaging, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Cliniques Universitaires Saint Luc, Brussels, Belgium. 9. Urology Unit, Academic Medical Centre Hospital 'Santa Maria della Misericordia', Udine, Italy. 10. Nuclear Medicine Unit, University of Bologna, S. Orsola Hospital Bologna, Bologna, Italy.
Abstract
CONTEXT: In patients treated for prostate cancer, a rising serum prostate-specific antigen (PSA) level is a first sign of relapse, but imaging is needed to determine the localization of the recurrence, which may be local, in lymph nodes, and/or metastatic. With the increasing success rate of earlier salvage therapy, the diagnosis has become pertinent when the recurrent PSA level is still very low. OBJECTIVE: To systematically review the literature on the role of the existing imaging techniques in patients with early recurrent prostate cancer. EVIDENCE ACQUISITION: A systematic literature search across the MEDLINE and EMBASE databases was conducted in February 2018, searching for original studies reporting on imaging in a (sub)group of patients with recurrent PSA levels not higher than 5ng/ml. This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The methodological quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. EVIDENCE SYNTHESIS: A total of 98 studies were included in this systematic review, reporting on the role of transrectal ultrasonography (TRUS), computed tomography (CT), bone scintigraphy (BS), single-photon emission CT, multiparametric magnetic resonance imaging (mpMRI), whole-body MRI (wbMRI), and positron emission tomography (PET)-CT/MRI using 18F fluoro-deoxy-glucose, 11C choline, 18F (fluoro)(methyl)choline, 11C acetate, 18F FACBC (fluciclovine) and prostate-specific membrane antigen (PSMA)-based tracers. CT and BS were not sufficiently sensitive in the early recurrence setting. For the detection of local recurrence, TRUS or mpMRI can be used; however, at the lowest PSA levels, few data were available, only after radical prostatectomy, showing a wide range of positivity. TRUS or mpMRI need to be combined with (PET)-CT to assess distant disease, but new techniques such as wbMRI, PET-MRI, or PET-CT allow for an all-in-one approach. At recurrent PSA levels <0.5ng/ml, detection rates up to 31.3% were reported using 11C choline PET-CT and up to 65.0% using 68Ga PSMA-11 PET-CT. At recurrent PSA levels <0.2ng/ml, detection rates of 68Ga PSMA-11 PET-CT ranged from 11.3% to as high as 58.3%. CONCLUSIONS: Detection rates of different imaging techniques depend on the PSA level at the time of imaging. Recent advanced imaging techniques may detect the localization of the recurrence, even when the PSA levels are still very low. PATIENT SUMMARY: In patients treated for prostate cancer, a rising serum prostate-specific antigen (PSA) level is a sign of recurrence of the disease. Advanced imaging techniques may demonstrate the localization of the recurrence, even when the PSA levels are still very low.
CONTEXT: In patients treated for prostate cancer, a rising serum prostate-specific antigen (PSA) level is a first sign of relapse, but imaging is needed to determine the localization of the recurrence, which may be local, in lymph nodes, and/or metastatic. With the increasing success rate of earlier salvage therapy, the diagnosis has become pertinent when the recurrent PSA level is still very low. OBJECTIVE: To systematically review the literature on the role of the existing imaging techniques in patients with early recurrent prostate cancer. EVIDENCE ACQUISITION: A systematic literature search across the MEDLINE and EMBASE databases was conducted in February 2018, searching for original studies reporting on imaging in a (sub)group of patients with recurrent PSA levels not higher than 5ng/ml. This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The methodological quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. EVIDENCE SYNTHESIS: A total of 98 studies were included in this systematic review, reporting on the role of transrectal ultrasonography (TRUS), computed tomography (CT), bone scintigraphy (BS), single-photon emission CT, multiparametric magnetic resonance imaging (mpMRI), whole-body MRI (wbMRI), and positron emission tomography (PET)-CT/MRI using 18F fluoro-deoxy-glucose, 11C choline, 18F (fluoro)(methyl)choline, 11C acetate, 18F FACBC (fluciclovine) and prostate-specific membrane antigen (PSMA)-based tracers. CT and BS were not sufficiently sensitive in the early recurrence setting. For the detection of local recurrence, TRUS or mpMRI can be used; however, at the lowest PSA levels, few data were available, only after radical prostatectomy, showing a wide range of positivity. TRUS or mpMRI need to be combined with (PET)-CT to assess distant disease, but new techniques such as wbMRI, PET-MRI, or PET-CT allow for an all-in-one approach. At recurrent PSA levels <0.5ng/ml, detection rates up to 31.3% were reported using 11C choline PET-CT and up to 65.0% using 68Ga PSMA-11 PET-CT. At recurrent PSA levels <0.2ng/ml, detection rates of 68Ga PSMA-11 PET-CT ranged from 11.3% to as high as 58.3%. CONCLUSIONS: Detection rates of different imaging techniques depend on the PSA level at the time of imaging. Recent advanced imaging techniques may detect the localization of the recurrence, even when the PSA levels are still very low. PATIENT SUMMARY: In patients treated for prostate cancer, a rising serum prostate-specific antigen (PSA) level is a sign of recurrence of the disease. Advanced imaging techniques may demonstrate the localization of the recurrence, even when the PSA levels are still very low.
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