PSMA PET Before Prostate Biopsy: From Lesion Detection to Biopsy Avoidance
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Mutaz Kassas1, Carlos Artigas1, Julien Anract2
1Department of Nuclear Medicine, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium.
Introduction:
Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) may refine biopsy selection when magnetic resonance imaging (MRI) is equivocal or nonsuspicious despite persistent clinical concern. This review aims to examine the prospective evidence and to distinguish diagnostic accuracy from biopsy avoidance.
Methods:
Selected prospective cohorts and randomized trials evaluating PSMA PET before prostate biopsy were synthesized narratively, alongside relevant systematic reviews and guidelines. Interpretation focused on patient selection, clinically significant prostate cancer (csPCa) definitions, biopsy protocols, and verification of PET-negative findings.
Results:
Combining PSMA PET with MRI improves sensitivity and negative predictive value in several prospective studies, particularly in men with equivocal findings. PET-targeted biopsy can improve sampling, but this does not establish the safety of omitting biopsy. In PRIMARY2, a PET-guided pathway achieved noninferior csPCa detection compared with systematic biopsy (12% versus 16%; prespecified noninferiority margin, 10 percentage points), while 49% of men in the PET arm avoided biopsy within 6 months. PET-negative men did not undergo routine immediate biopsy, so the trial does not establish histologically verified negative predictive value. Study heterogeneity and limited follow-up constrain generalization.
Conclusions:
PSMA PET may complement MRI in selected men with residual diagnostic uncertainty. Broader implementation requires validated clinical thresholds, longer follow-up after biopsy deferral, and evidence of cost-effectiveness.
