Prostate-specific antigen density does not predict metastatic disease on PSMA-PET in high-risk prostate cancer patients with negative conventional imaging

Authors

  • Ravi Kumar University of Toronto, Dept. of Surgery, Toronto, Canada
  • Katherine Lajkosz University of Toronto, Dept. of Biostatistics, Toronto, Canada
  • Ur Metser University of Toronto, Dept. of Medical Imaging, Toronto, Canada
  • Jimmy Misurka University Health Network, Dept. of Surgery, Division of Urology, Toronto, Canada
  • Jenna Hiemstra University of Toronto, Dept. of Surgery, Toronto, Canada
  • Jayson Kreidstein University of Toronto, Dept. of Surgery, Toronto, Canada
  • Lauren Calicchia University of Toronto, Dept. of Surgery, Toronto, Canada
  • Amalia Silberman University of Toronto, Dept. of Surgery, Toronto, Canada
  • Antonio Finelli University of Toronto, Dept. of Surgery, Toronto, Canada
  • Neil E. Fleshner University of Toronto, Dept. of Surgery, Toronto, Canada
  • Robert J. Hamilton University of Toronto, Dept. of Surgery, Toronto, Canada
  • Girish S. Kulkarni University of Toronto, Dept. of Surgery, Toronto, Canada
  • Alexandre Zlotta University of Toronto, Dept. of Surgery, Toronto, Canada
  • Alejandro Berlin Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Canada
  • Nathan Perlis University of Toronto, Dept. of Surgery, Toronto, Canada

DOI:

https://doi.org/10.5489/cuaj.9113

Keywords:

urology, medical imaging, Oncology (Prostate)

Abstract

INTRODUCTION: The ability of prostate-specific antigen density (PSAD) to predict metastatic disease on prostate-specific membrane antigen-positron emission tomography (PSMAPET) at initial staging in high-risk prostate cancer (PCa) for men with negative conventional imaging is unclear. We hypothesized that there might be a PSAD cutoff below which PSMAPET would be unnecessary, as it would so rarely identify metastatic disease.

METHODS: A retrospective cohort study of all men receiving 18F-DCFPyl PSMA-PET for primary staging between January 2018 and December 2022 at the University Health Network was performed. Student’s t-tests or Mann-Whitney U tests were used to compare continuous variables by PSMA-PET positivity status. Receiver operating characteristic curve analysis to compare PSA and PSAD performance and Chi-squared automatic interaction detector methodologies were used to identify predictors of metastatic disease.

RESULTS: A total of 140 men with high-risk PCa and negative conventional imaging were included. The median age was 68 years (interquartile range [IQR] 63-74). Median PSA and PSAD were 13.9 (IQR 6.9-29.5) and 0.36 ng/ml2 (IQR 0.19-0.83), respectively. PSMA-PET was positive in 40% of cases for metastatic disease. The area under the curve (AUC) to predict metastatic disease on PSMA-PET was 0.55 for PSAD (p=0.57). Patients with metastatic disease on PSMA-PET had higher Gleason grade group (GG) scores on biopsy (53 vs. 20% GG5, p<0.001) and more extraprostatic extension (19 vs. 6%, p=0.03) and perineural invasion (65 vs. 45%, p=0.03).

CONCLUSIONS: In this retrospective cohort, PSAD does not reliably predict which patients with high-risk PCa and negative conventional imaging will have metastatic disease unveiled by PSMA-PET.

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Published

2025-05-16

How to Cite

Kumar, R., Lajkosz, K., Metser, U., Misurka, J., Hiemstra, J., Kreidstein, J., … Perlis, N. (2025). Prostate-specific antigen density does not predict metastatic disease on PSMA-PET in high-risk prostate cancer patients with negative conventional imaging. Canadian Urological Association Journal, 19(9), E307–11. https://doi.org/10.5489/cuaj.9113

Issue

Vol. 19 No. 9 (2025): CUAJ September

Section

Original Research

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