Detection rate, pattern of relapse and influence on therapeutic decision of PSMA PET/CT in patients affected by biochemical recurrence after radical prostatectomy, a retrospective case series



68Ga-Prostate-specific membrane antigen (PSMA) PET/CT is widely used in patients with biochemical recurrence (BCR) after radical prostatectomy. We collected data about patients staged with PSMA PET/CT after BCR (PSA < 1 ng/ml) in four different institutes. Impact of baseline features (Gleason score, risk classification, PSA at recurrence, PSA doubling time and time to recurrence) was explored to understand predictive factors of (PSMA) PET/CT positivity. Impact of restaging on following treatment approaches was reported.


92 patients were included. PSMA PET/CT detection rate was 56.5% and low-volume disease (≤ 3 non-visceral lesions) was detected in 52.2% of patients. After positive scan, 13.5% of patients still lies on observation, ADT alone was administered in 30.8% of cases, Stereotactic body RT (SBRT) alone was delivered to 44.2% of patients and 11.5% of patients underwent concomitant SBRT and ADT. Seven patients underwent conventional salvage prostate bed RT. Chi-squared test showed a higher rate of positive PSMA PET/CT for patients with Gleason score > 7 (p = 0.004) and TTR < 29.5 months (p = 0.003).


PSMA PET/CT showed a high detection rate. This influenced clinical management in a significant percentage of patients, allowing treatment tailoring on the basis of imaging.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2


  1. 1.

    Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424.

    Article  Google Scholar 

  2. 2.

    Thompson IM, Valicenti RK, Albertsen P, Davis BJ, Goldenberg SL, Hahn C, et al. Adjuvant and salvage radiotherapy after prostatectomy: AUA/ASTRO guideline. J Urol. 2013;190(2):441–9.

    Article  Google Scholar 

  3. 3.

    Pisansky TM, Thompson IM, Valicenti RK, D’Amico AV, Selvarajah S. Adjuvant and salvage radiotherapy after prostatectomy: ASTRO/AUA guideline amendment 2018–2019. J Urol. 2019;202(3):533–8.

    Article  Google Scholar 

  4. 4.

    Tendulkar RD, Agrawal S, Gao T, Efstathiou JA, Pisansky TM, Michalski JM, et al. Contemporary update of a multi-institutional predictive nomogram for salvage radiotherapy after radical prostatectomy. J Clin Oncol. 2016;34(30):3648–54.

    Article  Google Scholar 

  5. 5.

    Borghetti P, Spiazzi L, Cozzaglio C, Pedretti S, Caraffini B, Triggiani L, et al. Postoperative radiotherapy for prostate cancer: the sooner the better and potential to reduce toxicity even further. Radiol Med. 2018;123(1):63–70.

    Article  Google Scholar 

  6. 6.

    Bottke D, Bartkowiak D, Siegmann A, Thamm R, Böhmer D, Budach V, et al. Effect of early salvage radiotherapy at PSA < 0.5 ng/ml and impact of post-SRT PSA nadir in post-prostatectomy recurrent prostate cancer. Prostate Cancer Prostatic Dis. 2019;22(2):344–9.

    CAS  Article  Google Scholar 

  7. 7.

    Stephenson AJ, Scardino PT, Kattan MW, Pisansky TM, Slawin KM, Klein EA et al. Predicting the outcome of salvage radiation therapy for recurrent prostate cancer after radical prostatectomy. J Clin Oncol. 2007 May 20;25(15):2035-41. Erratum in: J Clin Oncol. 2007;25(26):4153.

  8. 8.

    Eiber M, Maurer T, Souvatzoglou M, Beer AJ, Ruffani A, Haller B et al. Evaluation of Hybrid 68Ga-PSMA Ligand PET/CT in 248 Patients with Biochemical Recurrence After Radical Prostatectomy. J Nucl Med. 2015 May;56(5):668–74. Epub 2015 Mar 19. Erratum in: J Nucl Med. 2016;57(8):1325.

  9. 9.

    Troyer JK, Beckett ML, Wright GL Jr. Detection and characterization of the prostate-specific membrane antigen (PSMA) in tissue extracts and body fluids. Int J Cancer. 1995;62(5):552–8.

    CAS  Article  Google Scholar 

  10. 10.

    Zhang Q, Zang S, Zhang C, Fu Y, Lv X, Zhang Q, et al. Comparison of (68)Ga-PSMA-11 PET-CT with mpMRI for preoperative lymph node staging in patients with intermediate to high-risk prostate cancer. J Transl Med. 2017;15(1):230.

    Article  Google Scholar 

  11. 11.

    Afshar-Oromieh A, Zechmann CM, Malcher A, Eder M, Eisenhut M, Linhart HG, et al. Comparison of PET imaging with a (68)Ga-labelled PSMA ligand and (18)F-choline-based PET/CT for the diagnosis of recurrent prostate cancer. Eur J Nucl Med Mol Imaging. 2014;41(1):11–20.

    CAS  Article  Google Scholar 

  12. 12.

    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(4):403–17.

    Article  PubMed  Google Scholar 

  13. 13.

    Von Eyben FE, Picchio M, von Eyben R, Rhee H, Bauman G. (68)Ga-labeled prostate-specific membrane antigen ligand positron emission tomography/computed tomography for prostate cancer: a systematic review and meta-analysis. Eur Urol Focus. 2018;4(5):686–93.

    Article  Google Scholar 

  14. 14.

    McCarthy M, Francis R, Tang C, Watts J, Campbell A. A multicentre prospective clinical trial of 68Gallium PSMA HBED-CC PET-CT restaging in biochemically relapsed prostate carcinoma: Oligometastatic rate and distribution compared with standard imaging. Int J Radiat Oncol Biol Phys. 2019;104(4):801–8.

    Article  PubMed  Google Scholar 

  15. 15.

    Emmett L, van Leeuwen PJ, Nandurkar R, Scheltema MJ, Cusick T, Hruby G, et al. Treatment outcomes from (68)Ga-PSMA PET/CT-informed salvage radiation treatment in men with rising PSA after radical prostatectomy: prognostic value of a negative PSMA PET. J Nucl Med. 2017;58(12):1972–6.

    CAS  Article  Google Scholar 

  16. 16.

    Calais J, Czernin J, Cao M, Kishan AU, Hegde JV, Shaverdian N, et al. (68)Ga-PSMA-11 PET/CT mapping of prostate cancer biochemical recurrence after radical prostatectomy in 270 patients with a PSA level of less than 1.0 ng/mL: impact on salvage radiotherapy planning. J Nucl Med. 2018;59(2):230–7.

    CAS  Article  Google Scholar 

  17. 17.

  18. 18.

    Mottet N, Bellmunt J, Bolla M, Briers E, Cumberbatch MG, De Santis M, et al. EAU-ESTRO-SIOG Guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent. Eur Urol. 2017;71(4):618–29.

    Article  Google Scholar 

  19. 19.

    Corfield J, Perera M, Bolton D, Lawrentschuk N. (68)Ga-prostate specific membrane antigen (PSMA) positron emission tomography (PET) for primary staging of high-risk prostate cancer: a systematic review. World J Urol. 2018;36(4):519–27.

    Article  Google Scholar 

  20. 20.

    Zacho HD, Nielsen JB, Haberkorn U, Stenholt L, Petersen LJ. 68Ga-PSMA PET/CT for the detection of bone metastases in prostate cancer: a systematic review of the published literature. Clin Physiol Funct Imaging. 2017.

    Article  PubMed  Google Scholar 

  21. 21.

    Roach PJ, Francis R, Emmett L, Hsiao E, Kneebone A, Hruby G, et al. The impact of (68)Ga-PSMA PET/CT on management intent in prostate cancer: results of an Australian prospective multicenter study. J Nucl Med. 2018;59(1):82–8.

    CAS  Article  Google Scholar 

  22. 22.

    Beheshti M, Manafi-Farid R, Geinitz H, et al. Multi-phasic 68Ga-PSMA PET/CT in detection of early recurrence in prostate cancer patients with PSA < 1 ng/ml: a prospective study of 135 cases. J Nucl Med. 2020.

    Article  PubMed  Google Scholar 

  23. 23.

    Ost P, Reynders D, Decaestecker K, Fonteyne V, Lumen N, De Bruycker A, et al. Surveillance or metastasis-directed therapy for oligometastatic prostate cancer recurrence: a prospective, randomized, multicenter phase II trial. J Clin Oncol. 2018;36(5):446–53.

    CAS  Article  Google Scholar 

  24. 24.

    Saad F, Cella D, Basch E, Hadaschik BA, Mainwaring PN, Oudard S, et al. Effect of apalutamide on health-related quality of life in patients with non-metastatic castration-resistant prostate cancer: an analysis of the SPARTAN randomised, placebo-controlled, phase 3 trial. Lancet Oncol. 2018;19(10):1404–16.

    CAS  Article  Google Scholar 

  25. 25.

    Hussain M, Fizazi K, Saad F, Rathenborg P, Shore N, Ferreira U, et al. Enzalutamide in men with nonmetastatic, castration-resistant prostate cancer. N Engl J Med. 2018;378(26):2465–74.

    CAS  Article  Google Scholar 

  26. 26.

    Fizazi K, Shore N, Tammela TL, Ulys A, Vjaters E, Polyakov S, et al. Darolutamide in nonmetastatic, castration-resistant prostate cancer. N Engl J Med. 2019;380(13):1235–46.

    CAS  Article  Google Scholar 

  27. 27.

    Carrie C, Hasbini A, de Laroche G, Richaud P, Guerif S, Latorzeff I, et al. Salvage radiotherapy with or without short-term hormone therapy for rising prostate-specific antigen concentration after radical prostatectomy (GETUG-AFU 16): a randomised, multicentre, open-label phase 3 trial. Lancet Oncol. 2016;17(6):747–56.

    CAS  Article  Google Scholar 

  28. 28.

    Shipley WU, Seiferheld W, Lukka HR, Major PP, Heney NM, Grignon DJ, et al. Radiation with or without antiandrogen therapy in recurrent prostate cancer. N Engl J Med. 2017;376(5):417–28.

    Article  Google Scholar 

  29. 29.

    Schmidt-Hegemann NS, Stief C, Kim TH, et al. Outcome after PSMA PET/CT based salvage radiotherapy in patients with biochemical recurrence after radical prostatectomy: a bi-institutional retrospective analysis. J Nucl Med. 2018.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Onal C, Torun N, Akyol F, Guler OC, Hurmuz P, Yildirim BA, et al. Integration of 68Ga-PSMA-PET/CT in radiotherapy planning for prostate cancer patients. Clin Nucl Med. 2019;44(9):e510–6.

    Article  Google Scholar 

  31. 31.

    Müller J, Ferraro DA, Muehlematter UJ, Garcia Schüler HI, Kedzia S, Eberli D, et al. Clinical impact of (68)Ga-PSMA-11 PET on patient management and outcome, including all patients referred for an increase in PSA level during the first year after its clinical introduction. Eur J Nucl Med Mol Imaging. 2019;46(4):889–900.

    Article  Google Scholar 

  32. 32.

    Fendler WP, Calais J, Eiber M, Flavell RR, Mishoe A, Feng FY, et al. Assessment of 68Ga-PSMA-11 PET accuracy in localizing recurrent prostate cancer: a prospective single-arm clinical trial. JAMA Oncol. 2019;5(6):856–63.

    Article  Google Scholar 

  33. 33.

    Treglia G, Annunziata S, Pizzuto DA, Giovanella L, Prior JO, Ceriani L. Detection rate of 18F-labeled PSMA PET/CT in biochemical recurrent prostate cancer: a systematic review and a meta-analysis. Cancers (Basel). 2019;11(5):710.

    CAS  Article  Google Scholar 

  34. 34.

    Yilmaz U, Komek H, Can C, Altindag S. The role OF ((68)Ga)PSMA I&T in biochemical recurrence after radical prostatectomy: detection rate and the correlation between the level of PSA, Gleason score, and the SUV(max). Ann Nucl Med. 2019;33(8):545–53.

    CAS  Article  Google Scholar 

  35. 35.

    D’Angelillo RM, Francolini G, Ingrosso G, Ravo V, Triggiani L, Magli A, et al. Consensus statements on ablative radiotherapy for oligometastatic prostate cancer: a position paper of Italian Association of Radiotherapy and Clinical Oncology (AIRO). Crit Rev Oncol Hematol. 2019;138:24–8.

    Article  Google Scholar 

  36. 36.

    Ingrosso G, Carosi A, Di Cristino D, Ponti E, Lancia A, Murgia A, et al. Volumetric image-guided highly conformal radiotherapy of the prostate bed: toxicity analysis. Rep Pract Oncol Radiother. 2017;22(1):64–70.

    Article  Google Scholar 

  37. 37.

    Nath SK, Sandhu AP, Rose BS, Simpson DR, Nobiensky PD, Wang JZ, et al. Toxicity analysis of postoperative image-guided intensity-modulated radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys. 2010;78(2):435–41.

    Article  Google Scholar 

  38. 38.

    Bellavita R, Massetti M, Abraha I, Lupattelli M, Mearini L, Falcinelli L, et al. Conformal postoperative radiotherapy in patients with positive resection margins and/or pT3-4 prostate adenocarcinoma. Int J Radiat Oncol Biol Phys. 2012;84(3):e299–304.

    Article  Google Scholar 

  39. 39.

    Goldin GH, Sheets NC, Meyer AM, Kuo TM, Wu Y, Stürmer T, et al. Comparative effectiveness of intensity-modulated radiotherapy and conventional conformal radiotherapy in the treatment of prostate cancer after radical prostatectomy. JAMA Intern Med. 2013;173(12):1136–43.

    Article  Google Scholar 

  40. 40.

    Hershman DL, Unger JM, Wright JD, Ramsey S, Till C, Tangen CM, et al. Adverse health events following intermittent and continuous androgen deprivation in patients with metastatic prostate cancer. JAMA Oncol. 2016;2(4):453–61.

    Article  Google Scholar 

  41. 41.

    Bruni A, Ingrosso G, Trippa F, Di Staso M, Lanfranchi B, Rubino L, et al. Macroscopic locoregional relapse from prostate cancer: which role for salvage radiotherapy? Clin Transl Oncol. 2019.

    Article  PubMed  Google Scholar 

  42. 42.

    Francolini G, Jereczek-Fossa BA, Di Cataldo V, Simontacchi G, Marvaso G, Zerella MA, et al. Stereotactic radiotherapy for prostate bed recurrence after prostatectomy, a multicentric series. BJU Int. 2020;125(3):417–25.

    CAS  Article  Google Scholar 

  43. 43.

    Calais J, Czernin J, Fendler WP, Elashoff D, Nickols NG. Randomized prospective phase III trial of (68)Ga-PSMA-11 PET/CT molecular imaging for prostate cancer salvage radiotherapy planning [PSMA-SRT]. BMC Cancer. 2019 7;19(1):18. Erratum in: BMC Cancer. 2019;19(1):97.

  44. 44.

    Hollemans E, Verhoef EI, Bangma CH, Rietbergen J, Helleman J, Roobol MJ, et al. Prostate carcinoma grade and length but not cribriform architecture at positive surgical margins are predictive for biochemical recurrence after radical prostatectomy. Am J Surg Pathol. 2020;44(2):191–7.

    Article  Google Scholar 

Download references



Author information



Corresponding author

Correspondence to G. Francolini.

Ethics declarations

Conflict of interest

No conflict of interest has to be declared.

Ethics approval

Patients gave consent for the use of their anonymized data for research and educational purposes.

Informed consent

Patients gave consent for the use of their anonymized data for research and educational purposes.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Francolini, G., Detti, B., Bottero, M. et al. Detection rate, pattern of relapse and influence on therapeutic decision of PSMA PET/CT in patients affected by biochemical recurrence after radical prostatectomy, a retrospective case series. Clin Transl Oncol (2020).

Download citation


  • Prostate cancer
  • Biochemical recurrence
  • Radiotherapy