How PET-CT is Changing the Management of Non-metastatic Castration-resistant Prostate Cancer?: Comment la TEP-TDM Peut Modifier la Prise en Charge du Cancer de la Prostate Non Métastatique Résistant à la Castration ?

The aim of this narrative review conducted by the Prostate Cancer Committee of the French Association of Urology (CC-AFU) was to provide an update on the current evidence for the impact of PET/CT in the management of men with non-metastatic castration-resistant prostate cancer (nmCRPC). This review is based on data available in the literature on PET/CT imaging for staging nmCRPC patients. A PubMed search and narrative review of the data were performed in March 2022. Only articles in French or English were considered. Current guidelines recommend bone scan and CT scan as standard imaging modalities for staging and follow-up of patients with nmCRPC. Nearly one-third of asymptomatic patients with presumed nmCRPC ultimately have metastatic disease on conventional imaging. Increasing reports have shown that conventional imaging has limited accuracy in detecting metastatic disease in nmCRPC patients, leading to the development of next-generation imaging techniques. In a retrospective study, 18F-choline PET/CT detected distant metastases in 27/58 high-risk nmCRPC patients with prior negative conventional imaging. The implementation of radiolabeled ligands of the prostate-specific membrane antigen (PSMA) PET/CT in staging strategy has resulted in metastasis detection in 45% to 98% of patients with presumptive nmCRPC on conventional imaging. Such an early diagnosis of metastatic CRPC may allow patients to be referred for metastasis-directed therapies (i.e. stereotactic body radiotherapy), aimed at prolonging the efficacy of systemic therapies and improving clinical outcomes. However, current data are not strong enough to recommend this strategy, which must be properly evaluated in clinical trials. Indeed, the use of molecular imaging may lead to inappropriate undertreatment if the second-generation androgen receptor inhibitors (darolutamide, enzalutamide, apalutamide), which prolong life, are not used in the subgroup of patients with high PSA velocity (PSA doubling time <10 months). Implementation of PSMA-PET/CT in the staging strategy would result in a migration of disease stage to extra-pelvic, M1 disease in at least half of presumed nmCRPC patients. The unprecedented accuracy of PSMA-PET/CT may pave the way for a more personalized treatment strategy. However, no data yet support this strategy for all nmCRPC patients as no oncologic benefit of early detection of M1 disease or MDT has been demonstrated. © 2022 Elsevier Masson SAS. All rights reserved.

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Disclosure of interest A. Ruffion, M. Lasserre, P. Sargos, G. Fiard, E. Barret, J.-B. Beauval, and P. Rocchi have no competing interest to declare regarding this article. M. Gauthé declares competing interest by participating in clinical trials (as principal investigator, coordinator, or principal experimenter) for Curium Pharma, ABX Biochemical compounds, Endocyte/Novartis; participating in clinical trials (as co-investigator, non-principal experimenter, or collaborator) for Amgen; receiving compensation for advisory consultancies from Curium Pharma; being invited to conference as a speaker by Novartis, Astellas. C. Dariane declares competing interest by participating in clinical trials (as co-investigator, non-principal experimenter, or collaborator) for Janssen and Bayer; receiving compensation for advisory consultancies from Janssen, Bayer, Astellas; being invited to conference as a speaker by Janssen and being invited to congresses with paid expenses by Bayer. M. Rouprêt de declares competing interest by participating in clinical trials (as principal investigator, coordinator, or principal experimenter) for Roche, Janssen, AstraZeneca and by receiving compensation for advisory consultancies from Astellas, Ferring, Roche, Janssen, AstraZeneca, Bayer and Ipsen. G. Ploussard declares competing interest by participating in clinical trials (as principal investigator, coordinator, or principal experimenter) for Ferring, Janssen, Ipsen, AstraZeneca, Pfizer, Bayer; by participating in clinical trials (as co-investigator, non-principal experimenter, or collaborator) for Ferring, Janssen, Ipsen, AstraZeneca, Pfizer, Bayer; receiving compensation for advisory consultancies from Ferring, Janssen, Ipsen, AstraZeneca, Pfizer, Bayer, Astellas, Intuitive, Thermo Fisher; being invited to conference as a speaker by Ferring, Janssen, Ipsen, AstraZeneca, Pfizer, Bayer, Astellas, Intuitive, Thermo Fisher. G. Fromont declares competing interest by being invited as a speaker to conference by AstraZeneca and Astellas. R. Mathieu declares competing interest by receiving compensation for advisory consultancies from Bayer, Astellas, Janssen and by being invited as a speaker by Bayer, Astellas and Janssen. G. Roubaud declares competing interest by participating in clinical trials (as principal investigator, coordinator, or principal experimenter) for Bayer, Janssen, AAA, Novartis, Astellas, MSD, AstraZeneca; by receiving compensation for advisory consultancies from Merck and AstraZeneca; by being invited as a speaker to conferences by Jansses, AAA, Novartis, Astellas, AstraZeneca, Merck and by being invited to congresses with paid expenses by Astellas, Janssen and AstraZeneca. L. Brureau, G. Créhange, R. Renard-Penna did not disclose their conflict of interest.