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Radical prostatectomy without prior biopsy: an initial decision-making algorithm based on PSMA PET/mpMRI.

Zhuoran Li1,2, Jin Luo1,2, Qiwei Liu1,2

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This study introduces a new algorithm using PSMA PET/CT and mpMRI to select prostate cancer patients for surgery without biopsy. The method proved safe, feasible, and accurate for diagnosing clinically significant disease.

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Area of Science:

  • Oncology
  • Radiology
  • Urology

Background:

  • Advancements in radiological imaging suggest potential for biopsy-free prostate cancer (PCa) diagnosis.
  • Comprehensive evaluation of safety, feasibility, and accuracy is crucial for biopsy-free approaches.
  • This study focuses on an algorithm for selecting patients for radical prostatectomy without prior biopsy (RP-WPB).

Purpose of the Study:

  • To evaluate a novel decision-making algorithm for identifying suitable candidates for RP-WPB.
  • To assess the safety, feasibility, and diagnostic accuracy of using PSMA PET/CT and mpMRI for PCa diagnosis without biopsy.
  • To streamline the selection process for radical prostatectomy in specific PCa patient cohorts.

Main Methods:

  • A prospective decision-making algorithm was implemented for patient enrollment.
  • Key criteria included PSA levels, PI-RADS, miPSMA scores, and co-positive lesions on mpMRI and PSMA PET/CT.
  • Specific staging criteria (cT3-4, cN1, cM1) and PSA stratification for cT2N0M0 patients guided RP-WPB eligibility.

Main Results:

  • 120 patients underwent RP-WPB from January 2022 to February 2024, following the algorithm.
  • The detection rate of clinically significant PCa (ISUP grade ≥2) was 100%.
  • Pathological concordance was achieved in all cases with no perioperative complications exceeding Clavien-Dindo grade II.

Conclusions:

  • The PSMA PET/CT and mpMRI-based algorithm is safe, feasible, and highly accurate for selecting PCa patients for RP-WPB.
  • This approach offers a promising alternative to traditional biopsy for specific patient groups.
  • The study validates the diagnostic utility of advanced imaging in guiding PCa treatment decisions.