PSMA-11 PET/CT for Detection of Recurrent Prostate Cancer in Patients With Negative Choline PET/CT

Published:December 27, 2022DOI:


      • In France, PSMA-11 is granted by the National Agency for Medicine Security (ANSM) in selected prostate cancer patients.
      • PSMA-11 PET/CT detection rate in biochemical recurrence prostate cancer and negative choline PET/CT is not well known.
      • PSMA-11 PET/CT is able to detect occult biochemical recurrence even in a selected population of patients.
      • Majority of patients with a positive PSMA-11 PET/CT initiated a treatment.



      Prostate adenocarcinoma (CaP) is the leading cancer in men. After curative treatment, from 27% to 53% of patients will experience biochemical recurrence (BR). With the development of focal therapies, precise early identification of recurrence's sites is of utmost importance in order to deliver individualized treatment on positive lesions. The aim of this study was to assess the detection rate (DR) of 68Ga-PSMA-11 positron emission tomography/computed tomography (PET/CT) in selected patients with prostate cancer BR and recent negative 18F-choline PET/CT.

      Patients and Methods

      We performed a retrospective analysis including all patients with CaP referred for BR with a negative 18F-choline PET/CT, and who underwent 68Ga-PSMA-11 PET/CT between October, 2018 and December, 2019. The overall DR of 68Ga-PSMA-11 PET/CT was calculated, and described according to BR characteristics especially PSA levels and velocity. Patients were followed up for at least 1 year. Patient management following 68Ga-PSMA-11 PET/CT and PSA levels evolution after treatment were also recorded.


      One hundred fifty-nine patients comprising 164 examinations were analyzed. The overall DR of 68Ga-PSMA-11 PET/CT for BR was 65.9% (95CI, 58.6-73.1). The DR was 52.5% (95CI, 39.9-65.0), 70.6% (95CI, 55.3-85.9), 70.4% (95CI, 53.1-87.6), and 78.6% (95CI, 66.2-91.0) for PSA levels between 0.2 and 0.49 ng/mL, 0.5 to 0.99 ng/mL, 1 to 1.99 ng/mL and PSA ≥ 2 ng/mL, respectively. The DR was 70.7% (95CI, 59.0-82.4) with a PSA doubling time (PSA-DT) ≤6 months and 65.2% (95CI, 55.5-74.9) with a PSA-DT >6 months. Around 3/4 of patients (75.9%) with a positive 68Ga-PSMA-11 PET/CT initiated treatment, including surgery (2.4%), stereotactic radiotherapy ± androgen deprivation therapy (ADT) (22%) or external conformational radiotherapy ± ADT (46.3%). Patient management changed in 43 cases (39.8%).


      Our study confirmed the ability of 68Ga-PSMA-11 PET/CT to detect occult biochemical recurrence, even in a selected population of CaP patients with negative 18F-choline PET/CT, even at low PSA levels.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Genitourinary Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Sung H
        • Ferlay J
        • Siegel RL
        • et al.
        Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
        CA: Cancer J Clin. 2021; 71: 209-249
        • Mottet N
        • van den Bergh RCN
        • Briers E
        • et al.
        EAU-EANM-ESTRO-ESUR-SIOG guidelines on prostate cancer-2020 update. Part 1: screening, diagnosis, and local treatment with curative intent.
        Eur Urol. 2021; 79: 243-262
        • Arnold M
        • Karim-Kos HE
        • Coebergh JW
        • et al.
        Recent trends in incidence of five common cancers in 26 European countries since 1988: analysis of the European Cancer Observatory.
        Eur J Cancer. 2015; 51: 1164-1187
        • Cornford P
        • van den Bergh RCN
        • Briers E
        • et al.
        EAU-EANM-ESTRO-ESUR-SIOG guidelines on prostate cancer. Part II-2020 update: treatment of relapsing and metastatic prostate cancer.
        Eur Urol. 2021; 79: 263-282
        • Rozet F
        • Mongiat-Artus P
        • Hennequin C
        • et al.
        French ccAFU guidelines - update 2020-2022: prostate cancer.
        Prog Urol. 2020; 30: S136-S251
        • Phillips R
        • Shi WY
        • Deek M
        • et al.
        Outcomes of observation vs stereotactic ablative radiation for oligometastatic prostate cancer: the ORIOLE phase 2 randomized clinical trial.
        JAMA Oncol. 2020; 6: 650-659
        • Ost P
        • Reynders D
        • Decaestecker K
        • et al.
        Surveillance or metastasis-directed therapy for oligometastatic prostate cancer recurrence: a prospective, randomized, multicenter phase II trial.
        J Clin Oncol. 2018; 36: 446-453
        • Marvaso G
        • Volpe S
        • Pepa M
        • et al.
        Oligorecurrent prostate cancer and stereotactic body radiotherapy: where are we now? A systematic review and meta-analysis of prospective studies.
        Eur Urol Open Sci. 2021; 27: 19-28
        • Mazzola R
        • Francolini G
        • Triggiani L
        • et al.
        Metastasis-directed therapy (SBRT) guided by PET-CT (18)F-CHOLINE versus PET-CT (68)Ga-PSMA in castration-sensitive oligorecurrent prostate cancer: a comparative analysis of effectiveness.
        Clin Genitourin Cancer. 2021; 19: 230-236
        • Rogowski P
        • Roach 3rd M
        • Schmidt-Hegemann NS
        • et al.
        Radiotherapy of oligometastatic prostate cancer: a systematic review.
        Radiat Oncol. 2021; 16: 50
        • Salaun PY
        • Abgral R
        • Malard O
        • et al.
        Good clinical practice recommendations for the use of PET/CT in oncology.
        Eur J Nucl Med Mol Imaging. 2020; 47: 28-50
        • Emmett L
        • Metser U
        • Bauman G
        • et al.
        Prospective, multisite, international comparison of (18)F-fluoromethylcholine PET/CT, multiparametric MRI, and (68)Ga-HBED-CC PSMA-11 PET/CT in men with high-risk features and biochemical failure after radical prostatectomy: clinical performance and patient outcomes.
        J Nucl Med. 2019; 60: 794-800
        • Hofman MS
        • Lawrentschuk N
        • Francis RJ
        • et al.
        Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study.
        Lancet. 2020; 395: 1208-1216
        • Mena E
        • Black PC
        • Rais-Bahrami S
        • Gorin M
        • Allaf M
        • Choyke P.
        Novel PET imaging methods for prostate cancer.
        World J Urol. 2021; 39: 687-699
        • Perera M
        • Papa N
        • Roberts M
        • et al.
        Gallium-68 prostate-specific membrane antigen positron emission tomography in advanced prostate cancer-updated diagnostic utility, sensitivity, specificity, and distribution of prostate-specific membrane antigen-avid lesions: a systematic review and meta-analysis.
        Eur Urol. 2020; 77: 403-417
        • Hoffmann MA
        • Buchholz HG
        • Wieler HJ
        • et al.
        PSA and PSA kinetics thresholds for the presence of (68)Ga-PSMA-11 PET/CT-detectable lesions in patients with biochemical recurrent prostate cancer.
        Cancers. 2020; 12: 398
        • Aydin AM
        • Haberal B
        • Artykov M
        • Bilen CY
        • Yazici S.
        Clinicopathological predictors of positive (68)Ga-PSMA-11 PET/CT in PSA-only recurrence of localized prostate cancer following definitive therapy.
        Ann Nucl Med. 2019; 33: 326-332
        • Hoffmann MA
        • Buchholz HG
        • Wieler HJ
        • et al.
        The positivity rate of 68Gallium-PSMA-11 ligand PET/CT depends on the serum PSA-value in patients with biochemical recurrence of prostate cancer.
        Oncotarget. 2019; 10: 6124-6137
        • Afshar-Oromieh A
        • Holland-Letz T
        • Giesel FL
        • et al.
        Diagnostic performance of (68)Ga-PSMA-11 (HBED-CC) PET/CT in patients with recurrent prostate cancer: evaluation in 1007 patients.
        Eur J Nucl Med Mol Imaging. 2017; 44: 1258-1268
        • Fendler WP
        • Calais J
        • Eiber M
        • et al.
        Assessment of 68Ga-PSMA-11 PET accuracy in localizing recurrent prostate cancer: a prospective single-arm clinical trial.
        JAMA Oncol. 2019; 5: 856-863
        • Tan N
        • Bavadian N
        • Calais J
        • et al.
        Imaging of prostate specific membrane antigen targeted radiotracers for the detection of prostate cancer biochemical recurrence after definitive therapy: a systematic review and meta-analysis.
        J Urol. 2019; 202: 231-240
        • Pereira Mestre R
        • Treglia G
        • Ferrari M
        • et al.
        Correlation between PSA kinetics and PSMA-PET in prostate cancer restaging: a meta-analysis.
        Eur J Clin Invest. 2019; 49: e13063
        • Verburg FA
        • Pfister D
        • Heidenreich A
        • et al.
        Extent of disease in recurrent prostate cancer determined by [(68)Ga]PSMA-HBED-CC PET/CT in relation to PSA levels, PSA doubling time and Gleason score.
        Eur J Nucl Med Mol Imaging. 2016; 43: 397-403
        • Chevalme YM
        • Boudali L
        • Gauthe M
        • et al.
        Survey by the French Medicine Agency (ANSM) of the imaging protocol, detection rate, and safety of (68)Ga-PSMA-11 PET/CT in the biochemical recurrence of prostate cancer in case of negative or equivocal (18)F-fluorocholine PET/CT: 1084 examinations.
        Eur J Nucl Med Mol Imaging. 2021; 48: 2935-2950
        • Markowski MC
        • Sedhom R
        • Fu W
        • et al.
        Prostate specific antigen and prostate specific antigen doubling time predict findings on (18)F-DCFPyL positron emission tomography/computerized tomography in patients with biochemically recurrent prostate cancer.
        J Urol. 2020; 204: 496-502
        • Han S
        • Woo S
        • Kim YJ
        • Suh CH.
        Impact of (68)Ga-PSMA PET on the management of patients with prostate cancer: a systematic review and meta-analysis.
        Eur Urol. 2018; 74: 179-190
        • Calais J
        • Ceci F
        • Eiber M
        • et al.
        18)F-fluciclovine PET-CT and (68)Ga-PSMA-11 PET-CT in patients with early biochemical recurrence after prostatectomy: a prospective, single-centre, single-arm, comparative imaging trial.
        Lancet Oncol. 2019; 20: 1286-1294