A new study suggests that surgical removal of prostate cancer (PCa) can be accomplished without the need for preoperative biopsy.
The paper, published in the Chinese Medical Journal, outlines that by leveraging advanced imaging techniques, this novel approach could potentially transform the diagnostic and surgical landscape for prostate cancer.
PCa remains one of the most prevalent cancers among men, and the current diagnostic gold standard involves a biopsy guided by imaging modalities such as ultrasonography.
However, the limitations of this method are well-documented. Transrectal ultrasound-guided biopsies often yield poor sensitivity, leading to the detection of clinically insignificant cancers.
There are also high procedural costs and risks, including urinary tract infections.
A biopsy is generally required before proceeding to radical prostatectomy (RP), the surgical removal of the prostate gland.
To circumvent these challenges, researchers have turned to imaging strategies like multiparametric magnetic resonance imaging (mpMRI) and prostate-specific membrane antigen positron emission tomography (PSMA PET) combined with computed tomography (CT).
PSMA PET/CT identifies malignancies based on the uptake of radioactive tracers, quantified by the maximum standardised uptake value (SUVmax). Earlier clinical trials have demonstrated that combining PSMA PET/CT with mpMRI significantly reduces the likelihood of false-negative diagnoses of clinically significant PCa.
Building on this foundation, a research team led by Dr Nianzeng Xing from the National Cancer Centre/National Clinical Research Centre for Cancer and Cancer Hospital, Chinese Academy of Medical Sciences, in collaboration with Dr Yong Xu and Dr Raniu Liu from Tianjin Medical University, explored whether a combined PSMA PET/CT + mpMRI approach could eliminate the need for biopsy before RP. The study’s findings, published on August 23, 2024, highlight the potential of this innovative diagnostic pathway.
Between December 2017 and April 2022, the researchers enrolled 56 patients with suspected PCa from two tertiary hospitals who underwent RP without preoperative biopsy.
Patients were evaluated for consistency between clinical imaging results and pathological findings. Men presenting with elevated prostate-specific antigen (PSA) levels and/or abnormal findings on digital rectal examination were advised to undergo mpMRI. Imaging was deemed positive if the PI-RADS score was ≥4 for mpMRI or the SUVmax value was ≥4 for PSMA PET/CT.
Professor Xing said: ‘Only patients with high levels of prostate-specific antigen, positive mpMRI findings, and positive PSMA PET/CT findings who were unwilling to undergo biopsy were recommended for this biopsy-free approach.’
Postoperative pathology confirmed PCa in 55 of the 56 patients, with 49 cases identified as clinically significant. One patient was incorrectly diagnosed with high-grade prostatic intraepithelial neoplasia (HGPIN). Clinically significant PCa was associated with higher PSA levels, SUVmax values, and smaller prostate volumes.
Notably, the extracapsular extension was correctly identified in 21 of 26 cases, although it was misclassified as localised disease in five instances. When the SUVmax cut-off was raised to ≥7.5, the diagnostic accuracy for clinically significant PCa reached 100%.
Professor Xing added: ‘These findings underscore the potential of PSMA PET/CT + mpMRI as a diagnostic boon. This technique can significantly reduce medical costs, shorten hospitalisation periods, and avoid biopsy complications.’
Despite these promising outcomes, the researchers acknowledge the limitations of their study, particularly the small sample size.
They emphasise the need for larger-scale investigations and the integration of predictive models utilising next-generation imaging technologies and biomarkers to establish biopsy-free protocols for RP in the future.
Credit: Professor Nianzeng Xing from National Cancer Center/ Cancer Hospital of Chinese Academy of Medical Sciences
