68 Ga-PSMA-PET for radiation treatment planning in prostate cancer recurrences after surgery: Individualized medicine or new standard in salvage treatment

BACKGROUND 68Ga-PSMA-PET imaging is a novel promising diagnostic tool to locate early biochemical failure after radical prostatectomy (RP) in prostate cancer (PC) patients. Exact knowledge of the relapse location may result in changes of the therapy concept aside from changes to the TNM stage. To gain data for this approach, we evaluated PC patients receiving 68Ga-PSMA-PET imaging before salvage radiotherapy (RT). METHODS AND MATERIALS In this study, 100 patients with biochemical failure after RP± prior RT who underwent 68Ga-PSMA PET/CT or PET/MRI were evaluated undergoing salvage RT in our department. We analyzed TNM staging changes due to 68Ga-PSMA-PET imaging and its influence on RT planning and treatment. RESULTS Uptake indicative for tumor recurrence in 68Ga-PSMA-PET was found in 76% of the patients with biochemical recurrent PC. Median PSA level was 1.0 ng/mL (range 0.12-14.7 ng/mL). Of these, 80% showed no morphological correlate in the corresponding CT or MRI. A 43% of all patients experienced a change in TNM stage due to 68Ga-PSMA-PET imaging. Patients had changes from Tx to rcT+ (28%), 12% from pN0 to rcN1, 1% from pN0/cM0 to rcM1a, and 8% from cM0 to rcM1b. Due to the additional knowledge of 68Ga-PSMA-PET imaging, initial planned RT planning was adapted in 59% of all cases. An additional simultaneous integrated boost (SIB) to the prostate bed or lymph nodes was given to 32% and 63%, respectively. Ten patients received stereotactic body RT (SBRT) to single bone metastases. CONCLUSION 68Ga-PSMA-PET imaging showed a high clinical impact on staging and RT management in patients with biochemically recurrent PC, even at low serum PSA levels. With 43% changes in staging and 59% in radiotherapy planning 68Ga-PSMA-PET could lead to an indispensable tool in guiding radiation treatment in recurrent PC.