BPH-related False Positive of PSMA-PET in the Diagnosis of Prostate Cancer: the Achilles' Heel of Biopsy-free Radical Prostatectomy?

Abstract

Radical prostatectomy is one of the primary treatments for localized clinically significant prostate cancer. Generally, its application is based on prior biopsy. PSMA-PET is considered promising in biopsy-free radical prostatectomy. The expression of PSMA in benign prostatic hyperplasia tissue and corresponding positive reaction are crucial concerns for no biopsy strategy. Currently, no study has explored the benign prostatic hyperplasia-related false positive of PSMA-PET in the detection of prostate cancer. Furthermore, the influence of SUVmax and PI-RADS on biopsy-free radical prostatectomy is also poorly characterized. A retrospective study was conducted on patients who received PSMA-PET because of clinical suspicion of prostate cancer and were confirmed to be benign prostatic hyperplasia or prostate cancer. The receiver operating characteristic curve was generated for SUVmax. Results of interest were the false positive rate of PSMA-PET and the efficacy of SUVmax or mpMRI in excluding false positives. The benign prostatic hyperplasia-related false positive rate of PSMA-PET in detecting prostate cancer was 30%. SUVmax could effectively exclude benign prostatic hyperplasia and grade group 1 patients with an area under the curve of 0.86, the optimal SUVmax cutoff value with 100% specificity was 15, with a sensitivity of 41%. Notably, the sensitivity and specificity of stringent PET score and PI-RADS criteria (both ≥ 4) in diagnosing clinically significant prostate cancer were 49% and 100%, respectively. Our findings revealed benign prostatic hyperplasia-related false positive rate of PSMA-PET and provided a preliminary reference in biopsy-free radical prostatectomy.