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• W2965012954 abstract "•Prostate-specific membrane antigen (PSMA) PET/magnetic resonance (MR) imaging can help distinguish between patients with prostate cancer with locoregional recurrence and those with distant metastases, even at low prostate-specific antigen levels.•PSMA PET/MR imaging may have advantages compared with PET/computed tomography for the detection of local recurrence and anatomic correlates to PET-positive lymph node and bone lesions.•PSMA PET/MR imaging can help in making informed treatment decisions in patients with biochemical recurrence after radical prostatectomy.•PSMA PET/MR imaging enables dose-escalated and metastases-directed salvage radiotherapy in patients with biochemical recurrence after radical prostatectomy. •Prostate-specific membrane antigen (PSMA) PET/magnetic resonance (MR) imaging can help distinguish between patients with prostate cancer with locoregional recurrence and those with distant metastases, even at low prostate-specific antigen levels.•PSMA PET/MR imaging may have advantages compared with PET/computed tomography for the detection of local recurrence and anatomic correlates to PET-positive lymph node and bone lesions.•PSMA PET/MR imaging can help in making informed treatment decisions in patients with biochemical recurrence after radical prostatectomy.•PSMA PET/MR imaging enables dose-escalated and metastases-directed salvage radiotherapy in patients with biochemical recurrence after radical prostatectomy. Prostate cancer is the second most commonly diagnosed cancer type among men worldwide.1Siegel R.L. Miller K.D. Jemal A. Cancer statistics, 2017.CA Cancer J Clin. 2017; 67: 7-30Crossref PubMed Scopus (11045) Google Scholar Over the last decades, the number of patients increased drastically because of increasing incidence and the wide availability of serum prostate-specific antigen (PSA) tests. Prostate cancer is a highly heterogeneous disease and patients are stratified in risk groups based on clinical factors such as PSA level, T stage, and Gleason grade.2Mottet N. Bellmunt J. Bolla M. et al.EAU-ESTRO-SIOG Guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent.Eur Urol. 2017; 71: 618-629Abstract Full Text Full Text PDF PubMed Scopus (1815) Google Scholar Patients in the low-risk group usually do not require immediate treatment, but can be followed on active surveillance until disease progression warrants intervention. In contrast, patients in the intermediate-risk or high-risk group are usually offered radical treatment. Radical prostatectomy (RP) and radiotherapy (RT) are the 2 most common options for treatment with curative intent, with the former currently most used. However, approximately 30% of patients experience disease recurrence within 5 years after surgical removal of the prostate.3Freedland S.J. Presti J.C. Amling C.L. et al.Time trends in biochemical recurrence after radical prostatectomy: results of the SEARCH database.Urology. 2003; 61 (Available at:) (Accessed February 28, 2019): 736-741http://www.ncbi.nlm.nih.gov/pubmed/12670557Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 4Ward J.F. Blute M.L. Slezak J. et al.The Long-term clinical impact of biochemical recurrence of prostate cancer 5 or more years after radical prostatectomy.J Urol. 2003; 170: 1872-1876Crossref PubMed Scopus (206) Google Scholar Suspicion of prostate cancer recurrence is based on changes in PSA kinetics during the follow-up after initial treatment. After RP, biochemical recurrence (BCR) is defined as 2 consecutive increasing PSA values greater than 0.2 ng/mL.5Cornford P. Bellmunt J. Bolla M. et al.EAU-ESTRO-SIOG guidelines on prostate cancer. Part II: treatment of relapsing, metastatic, and castration-resistant prostate cancer.Eur Urol. 2017; 71: 630-642Abstract Full Text Full Text PDF PubMed Scopus (850) Google Scholar To decide on treatment of recurrent disease, it is of utmost importance to distinguish between patients who have locoregional confined disease, which is considered curable, and those with distant metastases. Salvage radiotherapy (sRT) to the prostate bed and possibly pelvic lymph nodes, with or without short-term androgen deprivation therapy (ADT), is the standard treatment option for the first group, whereas palliative long-term ADT is the common treatment option for the latter.5Cornford P. Bellmunt J. Bolla M. et al.EAU-ESTRO-SIOG guidelines on prostate cancer. Part II: treatment of relapsing, metastatic, and castration-resistant prostate cancer.Eur Urol. 2017; 71: 630-642Abstract Full Text Full Text PDF PubMed Scopus (850) Google Scholar However, patient stratification and treatment planning based on PSA values alone are challenging, because visual confirmation of the site of recurrence is lacking. Conventional imaging modalities are not sensitive enough to detect recurrent prostate cancer at the low PSA values with which patients typically present at the hospital.5Cornford P. Bellmunt J. Bolla M. et al.EAU-ESTRO-SIOG guidelines on prostate cancer. Part II: treatment of relapsing, metastatic, and castration-resistant prostate cancer.Eur Urol. 2017; 71: 630-642Abstract Full Text Full Text PDF PubMed Scopus (850) Google Scholar Importantly, this caveat leads to a more or less blind treatment approach with associated risks of overtreatment of patients with occult metastatic disease, and suboptimal treatment of patients with potentially curable disease. An imaging examination that provides better knowledge of the site of recurrence would alleviate these problems and could enable more personalized treatment strategies. Simultaneous PET/magnetic resonance (MR) imaging shows potential for improving the diagnosis in several cancer types.6Sotoudeh H. Sharma A. Fowler K.J. et al.Clinical application of PET/MRI in oncology.J Magn Reson Imaging. 2016; 44: 265-276Crossref PubMed Scopus (33) Google Scholar, 7Kwon H.W. Becker A.-K. Goo J.M. et al.FDG whole-body PET/MRI in oncology: a systematic review.Nucl Med Mol Imaging. 2017; 51: 22-31Google Scholar For prostate cancer, PET/MR imaging with prostate-specific membrane antigen (PSMA) ligands can provide images with excellent soft tissue contrast, as well as a superior sensitivity for detection of recurrent disease.8Barbosa F. Queiroz M. Nunes R. et al.Clinical perspectives of PSMA PET/MRI for prostate cancer.Clinics. 2018; 73Google Scholar This article discusses the emerging role of PSMA PET/MR imaging for the planning of sRT in patients with prostate cancer with BCR after RP. sRT is defined as the administration of RT to the prostatic bed and possibly to the surrounding tissues, including lymph nodes, in patients with BCR after initial RP but no evidence of distant metastatic disease.9Thompson I.M. Valicenti R.K. Albertsen P. et al.Adjuvant and salvage radiotherapy after prostatectomy: AUA/ASTRO Guideline.J Urol. 2013; 190: 441-449Crossref PubMed Scopus (296) Google Scholar The main advantage of sRT compared with adjuvant RT (aRT), which is the administration of RT after RP but before evidence of disease recurrence, is that the former avoids overtreatment and associated side effects in patients who would never develop recurrent cancer.9Thompson I.M. Valicenti R.K. Albertsen P. et al.Adjuvant and salvage radiotherapy after prostatectomy: AUA/ASTRO Guideline.J Urol. 2013; 190: 441-449Crossref PubMed Scopus (296) Google Scholar One retrospective study with 510 patients found that the 8-year metastasis-free survival and overall survival did not differ significantly between pT3N0 patients receiving aRT (92% and 89%, respectively) or observation plus early sRT (91% and 92%, respectively).10Fossati N. Karnes R.J. Boorjian S.A. et al.Long-term impact of adjuvant versus early salvage radiation therapy in pT3N0 prostate cancer patients treated with radical prostatectomy: results from a multi-institutional series.Eur Urol. 2017; 71: 886-893Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar Three ongoing prospective randomized controlled trials (ClinicalTrials.gov identifiers: NCT00541047, NCT00860652, NCT00667069) hope to shed more light on the potential differences in cancer control between aRT and sRT. Convincing evidence shows that sRT is most effective at low PSA values and should be commenced at the first signs of recurrence.11Stephenson A.J. Scardino P.T. Kattan M.W. et al.Predicting the outcome of salvage radiation therapy for recurrent prostate cancer after radical prostatectomy.J Clin Oncol. 2007; 25: 2035-2041Crossref PubMed Scopus (691) Google Scholar, 12Pfister D. Bolla M. Briganti A. et al.Early salvage radiotherapy following radical prostatectomy.Eur Urol. 2014; 65: 1034-1043Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 13Tendulkar R.D. Agrawal S. Gao T. et al.Contemporary update of a multi-institutional predictive nomogram for salvage radiotherapy after radical prostatectomy.J Clin Oncol. 2016; 34: 3648-3654Crossref PubMed Scopus (189) Google Scholar In a large multicenter study with patients initially treated with RP, Tendulkar and colleagues13Tendulkar R.D. Agrawal S. Gao T. et al.Contemporary update of a multi-institutional predictive nomogram for salvage radiotherapy after radical prostatectomy.J Clin Oncol. 2016; 34: 3648-3654Crossref PubMed Scopus (189) Google Scholar reported 5-year absence of BCR in 71% of patients with pre-sRT PSA levels between 0.01 and 0.2 ng/mL, 63% for PSA 0.21 to 0.5 ng/mL, 54% for 0.51 to 1 ng/mL, 43% for 1.01 to 2 ng/mL, and 37% for PSA greater than 2 ng/mL. Likewise, the cumulative rate of distant metastases significantly correlated with pre-sRT PSA levels, ranging from 9% to 27% for the lowest and highest PSA groups, respectively. Results of the Radiation Therapy Oncology Group (RTOG) 9601 randomized controlled trial showed that the addition of 24 months of ADT to early sRT resulted in significantly higher rates for overall survival (76.3% vs 71.3%) and lower incidences of metastatic disease (14.5% vs 23%) and death from prostate cancer (5.8% vs 13.4%) at 12 years.14Shipley W.U. Seiferheld W. Lukka H.R. et al.Radiation with or without antiandrogen therapy in recurrent prostate cancer.N Engl J Med. 2017; 376: 417-428Crossref PubMed Scopus (308) Google Scholar In the GETUG-AFU 16 randomized clinical trial, the addition of short-term ADT to early sRT had a significantly favorable effect on biochemical or clinical progression at 5-year follow-up (80% for sRT + ADT vs 62% for sRT alone), but no benefit on overall survival was found at time of analysis.15Carrie C. Hasbini A. de Laroche G. 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: 747-756Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar Similar results were recently reported from the interim analysis of the RTOG 0534 SPPORT trial, with 5-year freedom from progression in 71.1% of the patients who received prostate bed sRT alone versus 82.7% of patients who received sRT plus short-term ADT. A third arm with patients receiving additional irradiation of the pelvic lymph nodes showed significantly increased freedom from progression (89.1%) compared with the other 2 arms, as well as a significantly reduced likelihood of developing distant metastases at 8-year follow-up.16Pollack A. Karrison T.G. Balogh A.G. et al.Short term androgen deprivation therapy without or with pelvic lymph node treatment added to prostate bed only salvage radiotherapy: the NRG oncology/RTOG 0534 SPPORT trial.Int J Radiat Oncol. 2018; 102: 1605Abstract Full Text Full Text PDF Google Scholar The reduced likelihood of developing distant metastases represents the first evidence from a randomized controlled trial that extending the sRT field to the pelvic lymph nodes leads to clinically meaningful reductions in BCR in patients without previous evidence of lymph node involvement (N0/Nx). Computed tomography (CT) and bone scintigraphy (BS) are conventionally used to detect evidence of distant metastatic disease. However, these imaging modalities rarely detect disease at PSA levels less than 10 ng/mL, which limits their use for most candidates for sRT.5Cornford P. Bellmunt J. Bolla M. et al.EAU-ESTRO-SIOG guidelines on prostate cancer. Part II: treatment of relapsing, metastatic, and castration-resistant prostate cancer.Eur Urol. 2017; 71: 630-642Abstract Full Text Full Text PDF PubMed Scopus (850) Google Scholar Consequently, patient selection for sRT and consecutive treatment planning is often based on PSA kinetics and other clinical parameters alone, without visual evidence of the site of recurrence. In general, a patient with prostate cancer with BCR after RP is considered a candidate for sRT if benefit from treatment may be expected, taking into consideration the risk of death unrelated to prostate cancer. The expected benefit of sRT is usually calculated using nomograms that typically include clinical parameters such as pre-sRT PSA, PSA doubling time, Gleason score, seminal vesicle invasion, extracapsular extension, surgical margins, lymph node metastases, concurrent or neoadjuvant ADT, and radiation dose to predict the risk of being progression free at some time after treatment.11Stephenson A.J. Scardino P.T. Kattan M.W. et al.Predicting the outcome of salvage radiation therapy for recurrent prostate cancer after radical prostatectomy.J Clin Oncol. 2007; 25: 2035-2041Crossref PubMed Scopus (691) Google Scholar, 13Tendulkar R.D. Agrawal S. Gao T. et al.Contemporary update of a multi-institutional predictive nomogram for salvage radiotherapy after radical prostatectomy.J Clin Oncol. 2016; 34: 3648-3654Crossref PubMed Scopus (189) Google Scholar In general, men with a life expectancy greater than 10 years may benefit from sRT, often given in combination with short-term ADT or antiandrogens (6–24 months). The total radiation dose given to the prostate bed should be at least 66 Gy.5Cornford P. Bellmunt J. Bolla M. et al.EAU-ESTRO-SIOG guidelines on prostate cancer. Part II: treatment of relapsing, metastatic, and castration-resistant prostate cancer.Eur Urol. 2017; 71: 630-642Abstract Full Text Full Text PDF PubMed Scopus (850) Google Scholar A total radiation dose of 45 Gy to the whole pelvis is usually given in relapsing patients who had positive nodes on pelvic lymph node dissection (N1), although recent evidence shows that patients with negative or unknown pelvic lymph node stage (N0/Nx) may also benefit from pelvic lymph node irradiation.16Pollack A. Karrison T.G. Balogh A.G. et al.Short term androgen deprivation therapy without or with pelvic lymph node treatment added to prostate bed only salvage radiotherapy: the NRG oncology/RTOG 0534 SPPORT trial.Int J Radiat Oncol. 2018; 102: 1605Abstract Full Text Full Text PDF Google Scholar Clinical parameters are useful for predicting the patient’s population-based probability of benefiting from sRT.11Stephenson A.J. Scardino P.T. Kattan M.W. et al.Predicting the outcome of salvage radiation therapy for recurrent prostate cancer after radical prostatectomy.J Clin Oncol. 2007; 25: 2035-2041Crossref PubMed Scopus (691) Google Scholar, 13Tendulkar R.D. Agrawal S. Gao T. et al.Contemporary update of a multi-institutional predictive nomogram for salvage radiotherapy after radical prostatectomy.J Clin Oncol. 2016; 34: 3648-3654Crossref PubMed Scopus (189) Google Scholar However, they do not provide direct evidence of the location of recurrence, which is of paramount importance for more tailored treatment. The ideal imaging examination would detect local recurrence in the prostate bed (T+), lymph node metastases inside (N1) and outside the pelvis (M1a), bone metastases (M1b) and other distant metastases (M1c) at low PSA levels, in order to facilitate informed clinical decision making based on the tumor-node-metastasis (TNM) staging system. However, traditional imaging modalities all have their limitations; CT is not useful for detection of local recurrence because of lack of soft tissue contrast, whereas both CT and BS lack sensitivity for detection of lymph node and bone metastases at low PSA levels.17Kane C.J. Amling C.L. Johnstone P.A. et al.Limited value of bone scintigraphy and computed tomography in assessing biochemical failure after radical prostatectomy.Urology. 2003; 61: 607-611Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar MR imaging is excellent for assessment of local recurrence18Gaur S. Turkbey B. Prostate MR imaging for posttreatment evaluation and recurrence.Radiol Clin North Am. 2018; 56: 263-275Scopus (17) Google Scholar but also performs poorly for detection of small lymph node metastases.19Hövels A.M. Heesakkers R.A.M. Adang E.M. et al.The diagnostic accuracy of CT and MRI in the staging of pelvic lymph nodes in patients with prostate cancer: a meta-analysis.Clin Radiol. 2008; 63: 387-395Abstract Full Text Full Text PDF PubMed Scopus (559) Google Scholar Lately, there has been a strong focus on the development of prostate cancer–specific PET radiotracers, because alterations in molecular processes typically precede morphologic changes, thus providing opportunities for early detection of the site of recurrence. 11C-choline and 18F-fluciclovine are radiotracers that are currently US Food and Drug Administration approved for PET imaging in recurrent prostate cancer, whereas 18F-fluoromethylcholine is often used in clinical practice as well. Most recently, PSMA-based radiotracers that are typically labeled with 68Ga or 18F, depending on the subtype, are rapidly gaining popularity for detection of recurrent prostate cancer. The current European Association of Urology (EAU) guidelines state that choline PET/CT may be useful in selected patients with PSA level greater than 1 ng/mL, especially when PSA doubling time is less than 6 months.5Cornford P. Bellmunt J. Bolla M. et al.EAU-ESTRO-SIOG guidelines on prostate cancer. Part II: treatment of relapsing, metastatic, and castration-resistant prostate cancer.Eur Urol. 2017; 71: 630-642Abstract Full Text Full Text PDF PubMed Scopus (850) Google Scholar However, it has been consistently shown that choline PET has low detection rates at PSA levels less than 2 ng/mL.20Krause B.J. Souvatzoglou M. Tuncel M. et al.The detection rate of [11C]Choline-PET/CT depends on the serum PSA-value in patients with biochemical recurrence of prostate cancer.Eur J Nucl Med Mol Imaging. 2008; 35: 18-23Crossref PubMed Scopus (316) Google Scholar, 21Castellucci P. Ceci F. Graziani T. et al.Early biochemical relapse after radical prostatectomy: which prostate cancer patients may benefit from a restaging 11C-Choline PET/CT scan before salvage radiation therapy?.J Nucl Med. 2014; 55: 1424-1429Crossref PubMed Scopus (96) Google Scholar, 22Giovacchini G. Picchio M. Briganti A. et al.[ 11 C]Choline positron emission tomography/computerized tomography to restage prostate cancer cases with biochemical failure after radical prostatectomy and no disease evidence on conventional imaging.J Urol. 2010; 184: 938-943https://doi.org/10.1016/j.juro.2010.04.084Crossref PubMed Scopus (67) Google Scholar In a head-to-head comparison in 100 patients with BCR after RP, fluciclovine PET showed higher detection rates than choline PET at PSA levels less than 2 ng/mL (21% vs 14% for PSA <1 ng/mL, 45% vs 29% for PSA 1–2 ng/mL).23Nanni C. Zanoni L. Pultrone C. et al.18F-FACBC (anti1-amino-3-18F-fluorocyclobutane-1-carboxylic acid) versus 11C-choline PET/CT in prostate cancer relapse: results of a prospective trial.Eur J Nucl Med Mol Imaging. 2016; 43: 1601-1610Crossref PubMed Scopus (153) Google Scholar Several studies compared PSMA PET with choline PET scans of the same patients, and higher detection rates were consistently found for the former, especially at PSA levels less than 1 ng/mL.24Morigi J.J. Stricker P.D. van Leeuwen P.J. et al.Prospective comparison of 18F-Fluoromethylcholine versus 68Ga-PSMA PET/CT in prostate cancer patients who have rising PSA after curative treatment and are being considered for targeted therapy.J Nucl Med. 2015; 56: 1185-1190Crossref PubMed Scopus (372) Google Scholar, 25Afshar-Oromieh A. Zechmann C.M. Malcher A. et al.Comparison of PET imaging with a 68Ga-labelled PSMA ligand and 18F-choline-based PET/CT for the diagnosis of recurrent prostate cancer.Eur J Nucl Med Mol Imaging. 2014; 41: 11-20Crossref PubMed Scopus (646) Google Scholar, 26Schwenck J. Rempp H. Reischl G. et al.Comparison of 68Ga-labelled PSMA-11 and 11C-choline in the detection of prostate cancer metastases by PET/CT.Eur J Nucl Med Mol Imaging. 2017; 44: 92-101Crossref PubMed Scopus (164) Google Scholar In a recent review of the available literature on these 3 radiotracers, Evans and colleagues27Evans J.D. Jethwa K.R. Ost P. et al.Prostate cancer–specific PET radiotracers: a review on the clinical utility in recurrent disease.Pract Radiat Oncol. 2018; 8: 28-39Google Scholar reported median PSMA PET detection rates of 51.5% for PSA level less than 1 ng/mL, 74% for PSA 1 to 2 ng/mL, and 90.5% for PSA greater than 2 ng/mL. These values compared favorably with those of choline PET (19.5% for PSA level <1 ng/mL, 44.5% for PSA 1–2 ng/mL, and 76% for PSA >2 ng/mL) and fluciclovine PET (38% for PSA <1 ng/mL, 65% for PSA 1–2 ng/mL, and 78% for PSA >2 ng/mL). A large meta-analysis by Perera and colleagues28Perera 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. 2019; https://doi.org/10.1016/J.EURURO.2019.01.049Abstract Full Text Full Text PDF Google Scholar reported similar pooled detection rates for PSMA PET at low PSA levels. Specifically for patients with BCR after RP, these were 33% for PSA 0 to less than 0.2 ng/mL, 46% for PSA 0.2 to less than 0.5 ng/mL, 57% for PSA 0.5 to less than 1 ng/mL, 82% for PSA 1 to less than 2 ng/mL, and 97% for PSA greater than 2 ng/mL. Stratified by the site of recurrence, the pooled estimate of PSMA PET positivity for this patient group was 22% in the prostate bed, 36% in the pelvic lymph nodes, 7% in the extrapelvic lymph nodes, 15% in the bones, and 2% in the distant viscera. In summary, PSMA ligands seem to outperform other prostate cancer–specific PET tracers, especially because of their ability to detect recurrent disease at PSA levels less than 1 ng/mL. Recurrence is more often detected outside than inside the prostate bed,28Perera 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. 2019; https://doi.org/10.1016/J.EURURO.2019.01.049Abstract Full Text Full Text PDF Google Scholar even at PSA levels less than 0.5 ng/mL,29Meredith G. Wong D. Yaxley J. et al.The use of 68 Ga-PSMA PET CT in men with biochemical recurrence after definitive treatment of acinar prostate cancer.BJU Int. 2016; 118: 49-55Crossref PubMed Scopus (62) Google Scholar which indicates that offering sRT to the prostate bed alone is suboptimal for most patients. One limitation is that reliable histologic verification of the PSMA PET findings is often lacking in the setting of recurrent prostate cancer. Although some studies have used biopsies to confirm subsets of PSMA PET-positive lesions, this approach does not provide information on lesions that are false-negative on imaging. Consequently, the best estimates of the sensitivity and specificity of PSMA PET in patients with BCR after RP are obtained from patients who have undergone dissection of the pelvic lymph nodes for primary staging. The pooled sensitivity and specificity of PSMA PET in this setting were shown to be 77% and 97%, respectively, on a per-patient analysis, and 75% and 99%, respectively, on a per-lesion analysis.30Perera M. Papa N. Christidis D. et al.Sensitivity, specificity, and predictors of positive 68 Ga–prostate-specific membrane antigen positron emission tomography in advanced prostate cancer: a systematic review and meta-analysis.Eur Urol. 2016; 70: 926-937Abstract Full Text Full Text PDF PubMed Scopus (592) Google Scholar Modern PET scanners are combined with a CT or MR imaging scanner to provide anatomic reference and morphologic correlates that are complementary to the molecular information from PET. To date, most PSMA PET studies have been performed on PET/CT scanners and some on PET/MR imaging scanners, reflecting the different availability of these scanners. Nevertheless, there may be advantages of using PET/MR imaging instead of PET/CT for detection of prostate cancer recurrence, which can primarily be attributed to the superior soft tissue contrast of MR imaging compared with CT, as described later. After RP and lymph node dissection, the anatomy of the pelvis is greatly changed. Multiparametric MR imaging (mpMR imaging), which is the combination of anatomic T2-weighted (T2w) MR images and functional dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) MR images, allows differentiation between recurrent cancer, residual prostate tissue, inflammatory tissue, and fibrosis.18Gaur S. Turkbey B. Prostate MR imaging for posttreatment evaluation and recurrence.Radiol Clin North Am. 2018; 56: 263-275Scopus (17) Google Scholar Although T2w MR imaging is mainly used for anatomic reference, the addition of DCE and, to some extent, DW MR imaging has been shown to significantly increase the sensitivity to detect locally recurrent disease.31Panebianco V. Barchetti F. Sciarra A. et al.Prostate cancer recurrence after radical prostatectomy: the role of 3-T diffusion imaging in multi-parametric magnetic resonance imaging.Eur Radiol. 2013; 23: 1745-1752Crossref PubMed Scopus (90) Google Scholar Although the complementary nature of PSMA PET and MR imaging for detection of local recurrence remains to be clarified in large prospective studies, initial work with limited patient numbers and varying MR imaging protocols generally shows a favorable effect of combining the two modalities. In their study with 119 relapsing patients who underwent PSMA PET/CT and subsequent PET/MR imaging, Freitag and colleagues32Freitag M.T. Radtke J.P. Afshar-Oromieh A. et al.Local recurrence of prostate cancer after radical prostatectomy is at risk to be missed in 68Ga-PSMA-11-PET of PET/CT and PET/MRI: comparison with mpMRI integrated in simultaneous PET/MRI.Eur J Nucl Med Mol Imaging. 2017; 44: 776-787Crossref PubMed Scopus (82) Google Scholar found that mpMR imaging detected 18 cases of local recurrence, of which 9 were missed by the PET components of both PET/CT and PET/MR imaging. Lutje and colleagues33Lütje S. Cohnen J. Gomez B. et al.Integrated 68Ga-HBED-CC-PSMAPET/MRI in patients with suspected recurrent prostate cancer.Nuklearmedizin. 2017; 56: 73-81Google Scholar also detected more local recurrences with PET/MR imaging than with PET/CT (14 vs 9 in 25 patients), which was mainly attributed to the availability of MR images. In a small study with a trimodal PET/CT-MR imaging system, the addition of MR imaging was useful for cases with local recurrence, classified as indeterminate on PSMA PET/CT.34Alonso O. dos Santos G. García Fontes M. et al.68Ga-PSMA and 11C-Choline comparison using a tri-modality PET/CT-MRI (3.0 T) system with a dedicated shuttle.Eur J Hybrid Imaging. 2018; 2: 9Google Scholar Lake and colleagues35Lake S.T. Greene K.L. Westphalen A.C. et al.Optimal MRI sequences for 68Ga-PSMA-11 PET/MRI in evaluation of biochemically recurrent prostate cancer.EJNMMI Res. 2017; 7: 77Google Scholar found that DCE MR imaging was most effective for identifying PSMA-avid foci in the prostatic bed, and was able to detect additional lesions without associated PSMA uptake. The potential of PSMA PET/MR imaging for detection of local recurrence is further shown in Fig. 1, in which the mpMR imaging provides morphologic and functional correlates for a region with suspicious focal PSMA uptake in the prostate bed. For detection of lymph node and bone metastases, superiority of PSMA PET compared with both MR imaging and CT has been clearly shown.36Dyrberg E. Hendel H.W. Huynh T.H.V. et al.68Ga-PSMA-PET/CT in comparison with 18F-fluoride-PET/CT and whole-body MRI for the detection of bone metastases in patients with prostate cancer: a prospective diagnostic accuracy study.Eur Radiol. 2019; 29: 1221-1230Google Scholar, 37Zacho H.D. Nielsen J.B. Afshar-Oromieh A. et al.Prospective comparison of 68Ga-PSMA PET/CT, 18F-sodium fluoride PET/CT and diffusion weighted-MRI at for the detection of bone metastases in biochemically recurrent prostate cancer.Eur J Nucl Med Mol Imaging. 2018; 45: 1884-1897Google Scholar, 38Freitag M.T. Radtke J.P. Hadaschik B.A. et al.Comparison of hybrid 68Ga-PSMA PET/MRI and 68Ga-PSMA PET/CT in the evaluation of lymph node and bone metastases of prostate cancer.Eur J Nucl Med Mol Imaging. 2016; 43: 70-83Crossref PubMed Scopus (113) Google Scholar Nevertheless, PET/MR imaging may also have advantages compared with PET/CT in this setting. Freitag and colleagues38Freitag M.T. Radtke J.P. Hadaschik B.A. et al.Comparison of hybrid 68Ga-PSMA PET/MRI and 68Ga-PSMA PET/CT in the evaluation of lymph node and bone metastases of prostate cancer.Eur J Nucl Med Mol Imaging. 2016; 43: 70-83Crossref PubMed Scopus (113) Google Scholar found that the visibility of the lymph nodes was significantly higher on MR imaging from PET/MR imaging compared with low-dose CT from PET/CT, as was the overall conspicuity for bone lesions. Similarly, Afshar-Oromieh and colleagues39Afshar-Or" @default.
• W2965012954 created "2019-08-13" @default.
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• W2965012954 date "2019-10-01" @default.
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• W2965012954 title "Prostate-Specific Membrane Antigen PET/Magnetic Resonance Imaging for the Planning of Salvage Radiotherapy in Patients with Prostate Cancer with Biochemical Recurrence After Radical Prostatectomy" @default.
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