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OBJECTIVE: PSMA PET/CT has demonstrated superior sensitivity over conventional imaging in the detection of local and distant recurrence in biochemically relapsed (BCR) prostate cancer. We prospectively investigated the management impact of 68 Ga-PSMA PET/CT imaging in men with BCR, with the aim of identifying baseline clinicopathological predictors for management change. PATIENTS AND METHODS: Men with BCR who met eligibility criteria underwent 68 Ga-PSMA-11 PET/CT at Monash Health (Melbourne, Australia). Intended management plans were prospectively documented before and after 68 Ga-PSMA PET/CT imaging. Binary logistic regression analysis was performed to identify potential clinicopathological predictors of management change. Descriptive statistics were used to characterize the nature of these changes. RESULTS: Seventy men underwent 68 Ga-PSMA-11 PET/CT imaging. Median age was 67 years (IQR 63-72) and median PSA was 0.48 ng/ml (IQR 0.21-1.9). PSMA-avid disease was observed in 56% (39/70) of patients. Pre-scan management plan was altered following scanning in 43% (30/70) of patients. Management changes were significantly more common in patients with higher baseline PSA levels (PSA≥2 ng/ml, p = 0.01). 18/36 (50%) of the patients initially planned for watchful waiting had their management changed, including the use of salvage pelvic radiotherapy (n = 7) and stereotactic ablative body radiotherapy to oligometastatic disease (n = 6). CONCLUSION: Management change after 68 Ga-PSMA PET/CT for BCR is common and typically resulted in treatment intensification strategies in those planned for a watchful waiting approach. This study adds to the growing pool of evidence supporting the clinical utility of PSMA PET/CT imaging in the care of patients with BCR after definitive therapy.

AIM: To explore the utility of prostate specific membrane antigen (PSMA)-positron emission tomography (PET)/computed tomography (CT) in addition to conventional imaging prior to definitive external beam radiation treatment (EBRT) for prostate cancer. METHODS: All men undergoing PSMA-PET/CT prior to definitive EBRT for intermediate and high-risk prostate cancer were included in our ethics approved prospective database. For each patient, clinical and pathological results, in addition to scan results including site of PSMA positive disease and number of lesions, were recorded. Results of conventional imaging (bone scan, CT and multiparametric magnetic resonance imaging [MRI]) were reviewed and included. RESULTS: One hundred nine men underwent staging PSMA-PET/CT between May 2015 and June 2017; all patients had national comprehensive cancer network (NCCN) intermediate or high-risk prostate cancer and 87% had Gleason score (GS) 4 + 3 or higher. There was positive uptake corresponding to the primary in 108, equivocal in one. All patients with image detected nodal or bony lesions had GS 4 + 3 or more disease. Compared to conventional imaging with bone scan, CT and multiparametric MRI, PSMA-PET/CT upstaged an additional 7 patients (6.4%) from M0 to M1, 16 from N0M0 to N1M0 (14.7%) and downstaged 3 (2.8%) from M1 to M0 disease. CONCLUSION: PSMA-PET/CT identified the primary in 99% of patients, and altered staging in 21% of men with intermediate or high-risk prostate cancer referred for definitive EBRT compared to CT, bone scan and multiparametric MRI. Following this audit, we recommend the routine use of PSMA-PET/CT prior to EBRT in this patient group.

AIM: Certain metastasis-containing middle mediastinal lymph nodes cannot be approached by standard CT-guided brachytherapy. We here describe a novel trans-superior vena cava approach for such nodes. The aim of this prospective study was to assess the safety and clinical value of 125 iodine (I) brachytherapy via a trans-superior vena cava approach in patients with metastases in middle mediastinal lymph nodes. METHODS: From February 2008 to October 2011, 32 patients with 43 pathologically confirmed metastasis-containing mediastinal middle lymph nodes underwent CT-guided percutaneous 125 I brachytherapy via a trans-superior vena cava approach. Their complications and treatment responses were analyzed. Variations in blood pressure, heart rate, hemoglobin concentration and oxyhemoglobin saturation before, during and after the procedure were recorded, as were complications, including hemorrhage, pneumothorax and development of Breuer's reflex. Treatment response was assessed according to the response evaluation criteria for solid tumors Version 1.1. RESULTS: According to follow-up CT examination after 6 months, 22 patients (68.75%) achieved complete responses and four (12. 5%) partial responses. One patient died of myocardial infarction. Overall response rate was 81.25%, with a local control rate of 87.5%. The median survival was 25.7 months, with progression-free survival of 19.74 ± 0.81 months. The 1-year and 3-year overall survival rates were 53.13% and 28.13%. There were minimal immediate or delayed complications; no complications were severe. CONCLUSION: We consider this novel approach a safe means of treating certain mediastinal middle lymph node metastases.