PSMA PET/CT for prostate cancer diagnosis: current applications and future directions
Zhengang Shen, Li Zeng, Yunlong Li, Xiaodi Tang, Jiayi Lu, Li Chen, Z. Cheng, Hong Liao, Shukui Zhou
Abstract
Prostate cancer (PCa) requires improved diagnostic strategies beyond conventional imaging. This review aimed to evaluate the role of prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) in diagnosing advanced PCa. The review analyzed the diagnostic performance of PSMA PET/CT in various clinical contexts, including locoregional staging, extracapsular extension (ECE), seminal vesicle invasion (SVI), pelvic lymph node metastases, distant metastases, and biochemical recurrence (BCR). Further, challenges such as PSMA-negative tumors, need for standardized protocols, and potential of emerging imaging targets (neurotensin receptor 1 and fibroblast activation proteins) were reviewed. The role of artificial intelligence (AI) and advancements in tracer development were explored. PSMA PET/CT demonstrated exceptional specificity for locoregional staging, ECE, and SVI while reducing unnecessary biopsies and optimizing biopsy strategies. The diagnostic accuracy for pelvic lymph node metastases was higher with PSMA PET/CT than with traditional methods, although sensitivity for micrometastasis detection remained challenging. For distant metastases, PSMA PET/CT outperformed bone scintigraphy (BS) and conventional imaging, particularly in identifying bone and atypical lesions. In BCR cases, PSMA PET/CT reliably detected recurrent lesions at low prostate-specific antigen levels, significantly influencing treatment strategies. The review findings indicate that PSMA PET/CT is a superior diagnostic tool for PCa due to its high specificity and accuracy. Despite limitations such as PSMA-negative tumors and sensitivity challenges, advancements in AI, novel imaging targets, and affordable tracer development hold promise for broader clinical adoption. This review underscores the transformative potential of PSMA PET/CT in PCa diagnosis and management, advocating for ongoing research and protocol standardization.