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68Ga-PSMA PET SUVmax as a Predictor of Gleason Pattern 4 and Pathologic Upgrading in Intermediate Risk Prostate Cancer

  • Alan L. Xue,
  • Arveen A. Kalapara,
  • Zita E. Ballok,
  • Sidney M. Levy,
  • Dinesh Sivaratnam,
  • Andrew Ryan,
  • Shakher Ramdave,
  • Richard O’Sullivan,
  • Daniel Moon,
  • Jeremy P. Grummet,
  • Mark Frydenberg

Publication: Journal of Urology, September 2021


Accurate risk stratification remains a barrier for the safety of active surveillance in patients with intermediate-risk prostate cancer. [68Ga]Ga-PSMA-11 Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography (68Ga-PSMA PET/CT) and the maximum Standardized Uptake Value (SUVmax) may improve risk stratification within this population.

Materials and Methods

We reviewed men with ISUP Grade Group 2-3 disease on transperineal template biopsy undergoing 68Ga-PSMA PET/CT from November 2015 to January 2021. Primary outcome was the presence of high percentage Gleason pattern 4 (GP4) disease per-segment at surgery, at three thresholds: >/<50% GP4, >/<20% GP4, and >/<10% GP4. SUVmax was compared by GP4, and multivariable logistic regression examined the relationship between SUVmax and GP4. Secondary outcome was association between SUVmax and pathologic upgrading (GG1/2 to GG ≥3 from biopsy to surgery).


Of 220 men who underwent biopsy, 135 men underwent surgery. SUVmax was higher in high GP4 groups: 5.51 (IQR 4.19–8.49) vs 3.31 (2.64–4.41) >/<50% GP4 (p <0.001); 4.77 (3.31–7.00) vs 3.13 (2.64–4.41) >/<20% GP4 (p <0.001); and 4.54 (6.10–3.13) vs 3.03 (2.45–3.70) >/<10% GP4 (p <0.001). SUVmax remained an independent predictor of >50% (OR=1.39 [95%CI 1.18–1.65], p <0.001) and >20% (OR=1.24 [1.04–1.47], p=0.015) GP4 disease per-segment, and of pathologic upgrading (OR=1.22 [1.01–1.48], p=0.036). SUVmax threshold 4.5 predicted >20% GP4 with 58% specificity, 85% sensitivity, positive predictive value (PPV) 75% and negative predictive value (NPV) 72%. Threshold 5.4 predicted pathologic upgrading with 91% specificity and NPV 94%.


SUVmax on 68Ga-PSMA PET/CT is associated with GP4. SUVmax may improve risk stratification for men with intermediate-risk prostate cancer.