Diagnostic Accuracy of PSMA-PET/CT vs. mpMRI in Primary Staging of Intermediate- and High-Risk Prostate Cancer

Prostate-specific membrane antigen (PSMA) is markedly overexpressed in prostate cancer (PCa), and there is growing evidence to support its usefulness in initial diagnostic assessments. This study compares the diagnostic performance of PSMA positron emission tomography/computed tomography (PET/CT) and magnetic resonance imaging (mpMRI) in evaluating seminal vesicle invasion (SVI), extraprostatic extension (EPE), and pelvic lymph node involvement before radical prostatectomy.

A retrospective, single-institution analysis was performed. From a cohort of 325 patients who underwent radical prostatectomy between June 2022 to November 2024, 85 had undergone preoperative PSMA PET/CT for intermediate- and high-risk disease at biopsy, forming our study group. Two blinded specialists, one in radiology and one in nuclear medicine, independently interpreted the scans, using histopathological results as the reference standard. The primary outcome was diagnostic accuracy for T- and N-stage classification, while the secondary outcomes included the correct identification of the index lesion and comparative performance for each modality.

The study cohort comprised patients with intermediate-to-high-risk prostate cancer (median age: 66 years; median PSA level: 11.6 ng/mL; median PSA density: 0.3 ng/mL/cm³). Forty-eight patients presented with an ISUP grade of 3 or higher on biopsy. PSMA PET/CT was more sensitive than MRI for detecting EPE (72.2% vs. 46.9%) and nodal metastases (91.7% vs. 8.3%). Furthermore, PSMA PET/CT demonstrated significantly higher concordance with histopathological findings in index tumor localization (76.5% vs. 67.9%, p < 0.001). An exploratory analysis revealed a potential age-dependent pattern, but this requires confirmation in larger studies.

In this select cohort, PSMA PET/CT demonstrated greater accuracy than MRI for locoregional staging in patients with intermediate-to-high-risk prostate cancer (PCa). However, the generalizability of these findings is limited by the retrospective design and potential selection bias. These results suggest that PSMA PET/CT may have a valuable role in the initial staging workflow, but this needs to be confirmed in larger, prospective studies. An exploratory analysis suggested a potential age-dependent pattern, but this requires confirmation in larger studies.