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PEER-TO-PEER CLINICAL CONVERSATIONS
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Persistent PSA After Prostatectomy: Timing and Mortality Risk Implications - Journal Club
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Rashid Sayyid, MD, MSc and Zachary Klaassen, MD, MSc
Rashid Sayyid is joined by Zachary Klaassen to discuss a study examining persistent PSA following radical prostatectomy and mortality risk. The study revealed a counterintuitive finding: among patients with persistent PSA at 2-3 months post-surgery, those with pre-surgical PSA >20 had significantly better survival outcomes than those with PSA ≤20—a 31% reduction in all-cause mortality and 59% reduction in prostate cancer-specific mortality.
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| PSMA-PET Improves Metastasis-Free Survival in Salvage Radiotherapy for Prostate Cancer |
| Antony Pellegrino, MD |
| Zachary Klaassen discusses with Antony Pellegrino the impact of PSMA-PET versus conventional imaging for biochemical recurrence after prostatectomy. Using 601 patients with negative PSMA-PET scans and propensity score matching to control for clinical differences, the researchers demonstrate that patients staged with conventional imaging had double the two-year cumulative risk of metastasis compared to those staged with PSMA-PET. |
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PRIMARY Score and Where it Plays a Role in Prostate Cancer Diagnosis "Presentation"
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Michael Hofman, MBBS, FRACP, FAANMS, FICIS, GAICD
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| Michael Hofman presents the PRIMARY score for PSMA PET in prostate cancer diagnosis. He explains how PSMA PET complements MRI, preventing missed clinically significant cancers (17%) and details the five-point scoring system where 1-2 suggests benign and 3-5 indicates increasing cancer likelihood.
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| PRIMARY Score and Where it Plays a Role |
| Michael Hofman, MBBS, FRACP, FAANMS, FICIS, GAICD |
| Michael Hofman highlighted the diagnostic potential of PSMA PET/CT and the development of the PRIMARY score, showing that PSMA PET combined with MRI improves sensitivity and negative predictive value in detecting clinically significant prostate cancer, though at the cost of specificity. While PSMA PET may allow some patients to avoid biopsy, especially with high SUVmax values, further validation from trials like PRIMARY2 is needed to assess whether biopsy can be safely skipped in select cases. |
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| Can PSMA-Targeted Prostate Biopsy Detect Cancer When MRI-Guided Biopsy is Negative?
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| Wayne Brisbane, MD
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| Wayne Brisbane presented a phase 1 trial showing that PSMA-targeted prostate biopsy can detect clinically significant prostate cancer (Grade Group 2+) in patients who had negative or low-grade MRI-guided biopsies. Among patients with PSMA-avid lesions (SUVmax ≥3), 41% were found to have Grade Group 2+ disease, including cases with no MRI-visible lesions, demonstrating PSMA PET's value as a complementary diagnostic tool.
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| Prospective, Randomized Trial Comparing PSMA PET/CT and MRI-Guided Versus MRI Only-Guided Prostate Biopsy for Identification of Clinically Significant Prostate Cancer |
| Ida Sonni, MD |
| Ida Sonni presented results from a randomized phase II trial comparing PSMA PET/CT + mpMRI-guided biopsy versus mpMRI-only biopsy in men with PI-RADS 4 lesions. While overall detection rates of clinically significant prostate cancer were similar between groups at the patient level, PSMA PET/CT showed significantly higher positive predictive value at the lesion level compared to MRI. These findings suggest that PSMA PET/CT may enhance lesion-level detection accuracy, though further analysis is needed upon full trial completion. |
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| The Potential Utility of PSMA PET/CT in Prostate Cancer Biochemical Failure - A Global Retrospective Cohort Study |
| Brittany Miles, MD |
| Brittany Miles presented a global retrospective study showing that prostate cancer patients with biochemical recurrence after prostatectomy were twice as likely to receive salvage radiation therapy if they underwent PSMA PET/CT imaging compared to those who did not. The study highlights the potential of PSMA PET/CT to guide earlier and more confident treatment decisions due to its high sensitivity and specificity, especially at low PSA levels, though limitations include a lack of clinical risk stratification. |
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| Impact of Previous Pelvic Radiotherapy on PSMA PET Outcomes in Patients Experiencing Biochemical Recurrence after Radical Prostatectomy. Implications for Optimal Timing of Restaging |
| Armando Stabile, MD |
| Armando Stabile presented a multicenter study showing that prior pelvic radiotherapy increases the likelihood of a positive PSMA PET in men with biochemical recurrence after radical prostatectomy, especially at lower PSA levels. The findings suggest that in patients with prior pelvic radiation, earlier PSMA PET restaging may improve detection of recurrent or metastatic disease, particularly distant (miM1) lesions, informing more timely treatment decisions. |
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| Which Are the Prognostic Implications of a Negative PSMA-PET at the Time of Biochemical Recurrence in Prostate Cancer Patients Treated With Radical Prostatectomy? Selection of Salvage Therapies Candidates |
| Antony Pellegrino, MD |
| Antony Pellegrino presented data showing that prostate cancer patients with biochemical recurrence after radical prostatectomy who have a negative PSMA PET scan and receive salvage radiotherapy (sRT) experience significantly lower metastasis rates at 24 months compared to those with negative conventional imaging. This suggests that PSMA PET-negative patients are better selected for sRT and have improved metastasis-free survival, supporting the use of PSMA PET for refining treatment decisions in this setting. |
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