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Disease Spotlight: Prostate Cancer

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There are several ongoing clinical trials looking at the use of alpha-emitting, prostate-specific membrane antigen (PSMA)-targeting therapy for patients with prostate cancer (PCa), according to Jeremie Calais, M.D., Ph.D. During a 

, Dr. Calais suggested the potential of this modality’s efficacy and reduced side effects could eventually lead to a significant role in this patient population.

“Maybe in 10 years, I think Pluvicto will be replaced by alpha-emitting agents targeting PSMA. That may be something that I foresee,” posited Dr. Calais, the director of the clinical research program with the Ahmanson Translational Theranostics Division at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA).

While cautioning that the research is in the “very early days on alpha emitters,” Robert Flavell, M.D., Ph.D., said preliminary data has shown encouraging efficacy and noted other potential attributes.

“The side effect profile is a little different with the alpha emitters. They seem to have a much more pronounced xerostomia or a dry mouth, but perhaps less toxicity in other areas like the bone marrow. So we'll see how that all plays out. Another potential advantage for alpha emitters is relatively simplified radiation handling because you're typically giving much lower administered activities, and they have lower gamma fractions, so the patients are emitting a lot less radiation to the environment and to family members,” pointed out Dr. Flavell, the chief of molecular imaging and the Therapeutics Clinical Section in the Department of Radiology and Biomedical Imaging at the University of California, San Francisco (UCSF).

(Editor’s note: For related content, see “

The Reading Room Podcast: Emerging Trends with Theranostics in Prostate Cancer, Part 1

PSMA PET/CT Facilitates Better Long-Term Survival Rates After Salvage Radiotherapy for Recurrent PCa

SNMMI: Can Multimodal Monitoring Bolster Outcomes with Pluvicto in Treating mCRPC?

For more insights from Dr. Calais and Dr. Flavell, listen below or 

In the second of a two-part podcast episode, Jeremie Calais, M.D., and Robert Flavell, M.D., discuss current and emerging alpha-emitting therapies, possible roles for artificial intelligence (AI), and what the future may hold for theranostic applications in patients with prostate cancer.

The Reading Room Podcast: Emerging Trends with Theranostics in Prostate Cancer, Part 2

More and more urologists and medical oncologists are incorporating findings from prostate-specific membrane antigen positron emission tomography (PSMA PET) into restaging decisions for patients being treated for prostate cancer (PCa), noted Jeremie Calais, M.D., Ph.D., during a 

Dr. Calais said PSMA PET agents help provide rapid and significant insight into the impact of treatment on prostate tumor volume changes.

“(It provides) major information you can monitor for the appearance of new lesions expressing PSMA or not, with the CT information, and combining that with PSA (prostate-specific antigen) and ctDNA (circulating tumor DNA) can really give you refined tumor response assessment after, you know, two cycles. I think everybody should get at least two cycles and then see if you want to continue or not, and maybe you can expect to have to change your management based on that,” asserted Dr. Calais, the director of the theranostics program with the Ahmanson Translational Theranostics Division at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA).

Robert Flavell, M.D., Ph.D., added that single-photon emission computed tomography (SPECT) offers significant utility for evaluating the effectiveness of lutetium Lu 177 vipivotide tetraxetan (Pluvicto), particularly among patients who have low PSA secretion.

“One thing to remember with the lutetium PSMA therapy is that you can use the radiation from the therapy to generate an image. It does, in fact, admit a lower fraction of gammas. So if you perform SPECT imaging with every cycle, you essentially get a free PET scan every cycle without administrating additional radiopharmaceutical. We've definitely found this is pretty useful for following response to therapy,” pointed out Dr. Flavell, the chief of molecular imaging and the therapeutics clinical section in the Department of Radiology and Biomedical Imaging at the University of California, San Francisco (UCSF).

SNMMI: 18F-Piflufolastat PSMA PET/CT Offers High PPV for Local PCa Recurrence Regardless of PSA Level

SNMMI: Can 18F-Fluciclovine PET/CT Bolster detection of PCa Recurrence in the Prostate Bed?

SNMMI: What a New Meta-Analysis Reveals About Radiotracers for PET/CT Detection of PCa

In the first of a two-part podcast episode, Jeremie Calais, M.D., and Robert Flavell, M.D., discuss recent advances with PSMA-targeted radiotracers in the treatment of metastatic castration-resistant prostate cancer (mCRPC), and the role of imaging criteria in monitoring patients treated with PSMA-targeted radionuclide therapy.

While a new meta-analysis of the PI-RADS v2.1 criteria showed 96 percent and 88 percent sensitivity rates for 88 and PI-RADS category > 4 assessments respectively, researchers noted a high risk of bias in 29 percent of the reviewed studies.

What a New Meta-Analysis Reveals About the PI-RADS v2.1 System for Prostate MRI

In the 160-patient study comparing 18F-PSMA 1007 PET/CT and 18F-NaF PET/CT, the use of 18F-PSMA PET/CT led to 38 patients being restaged as having more advanced prostate cancer.

Study: PSMA PET/CT Leads to Metastatic Staging Changes in 25 Percent of Patients with Newly Diagnosed High-Risk PCa

PSMA PET offered 18 percent higher accuracy for detecting biochemical recurrence of PCa in contrast to mpMRI, according to findings from a 67-study meta-analysis.

Meta-Analysis Shows Benefits of PSMA PET in Detecting Recurrence and Metastasis with PCa

Abbreviated biparametric MRI demonstrated nearly equivalent detection rates for clinically significant and clinically insignificant prostate cancer as multiparametric MRI, according to research involving 22 centers in 12 countries.

Multicenter Study Finds Abbreviated MRI Non-Inferior to mpMRI for csPCa Detection

New research shows that over 94 percent of patients who had a PSA level of < 0.2 ng/mL and low-volume disease assessment six months after initiation of apalutamide and androgen deprivation therapy (ADT) for metastatic hormone-sensitive prostate cancer had radiographic progression-free survival at 24 months.

Study Emphasizes PSA and PSMA PET Tumor Volume Assessment for Predicting mHSPC Progression After Apalutamide and ADT 

Discussing investigational prostate-specific membrane antigen (PSMA) positron emission tomography (PET) agents being evaluated in current trials for prostate cancer (PCa) imaging, Emmanuel S. Antonarakis, M.D., said copper CU-64 PSMA I&T, currently the subject of two separate ongoing studies, may offer potential advantages to the currently approved agents Ga-68 PSMA-11 and piflufolastat F18.

“(CU-64 PSMA I&T has) a higher tumor-specific uptake, which means that you could theoretically get improved lesion contrast with the potential to detect smaller lesions. Because of the longer half life, there's an option to do the imaging 24 hours or 48 hours after the injection of the agent, and that may concentrate better in the tumor as opposed to the adjacent normal organs,” noted Dr. Antonarakis, a Clark Endowed Professor of Medicine, director of genitourinary oncology and associate director for translational research with the Masonic Cancer Center at the University of Minnesota.

(Editor’s note: For additional insights on prostate cancer imaging, click 

In addition to PSMA, other cell surface targeting approaches may offer potential utility in prostate cancer imaging, according to Dr. Antonarakis.

“There are other cell surface targets that we think are highly expressed in prostate cancer that could also one day become targets for imaging,” suggested Dr. Antonarakis. “For example, there's a protein called STEAP1 (Six-transmembrane epithelial antigen of prostate 1). There's a protein called B7-H3 and there's a protein called TROP2, and these are examples of cell surface proteins.”

Current Perspectives on Prostate Cancer and Emerging Theranostic Agents, Part 1

For more insights from Dr. Antonarakis, watch the video below.

In the second part of a recent interview, Emmanuel S. Antonarakis, M.D. discusses PSMA PET agents in current trials and cell surface proteins that may offer targeting utility in prostate cancer imaging beyond PSMA.

Current Perspectives on Prostate Cancer and Emerging Theranostic Agents, Part 2

While a recent report from the American Cancer Society noted a 3 percent annual increase in prostate cancer (PCa) incidence and a 4.6-4.8 percent annual increase in advanced PCa diagnoses from 2014 to 2021, Emmanuel S. Antonarakis, M.D. said it is important to keep these statistics in perspective.

In addition to a downturn in PSA screening after an adverse recommendation from the U.S. Preventive Services Task Force (USPSTF) in 2012 and the aging of the population, there has been a “stage migration” with the advent of prostate-specific membrane antigen positron emission tomography (PSMA PET) contributing to the rise of advanced PCa detection, noted Dr. Antonarakis in a recent interview with 

“The reason why I am confident calling it a stage migration is that if you look at the mortality from prostate cancer during that same time frame, it has not increased. It's been relatively stable. So despite an increasing incidence and despite an increasing advanced disease prevalence, we are not seeing an increase in mortality. … The advent of these PSMA PET scans and other molecular imaging, while they increase the detection of disease, they will also artificially increase the number of advanced patients that are diagnosed,” explained Dr. Antonarakis, a Clark Endowed Professor of Medicine and director of genitourinary oncology with the Masonic Cancer Center at the University of Minnesota.

In discussing emerging theranostic approaches to treating PCa, Dr. Antonarakis noted the potential of the radioligand agent 177Lu-PSMA-I&T for patients with metastatic castration-resistant prostate cancer (mCRPC). While this modality is currently being evaluated in a phase 3 clinical trial, Dr. Antonarakis suggested that 177Lu-PSMA-I&T may emerge as a viable alternative prior to chemotherapy in this patient population.

“I would be extremely interested to see also how the overall survival looks. … We do not know if this is going to be the case, but if the overall survival is also positive, to me, that would be an advantage for a medical oncologist to select PSMA-I&T as opposed to PSMA-617, which the latter did not demonstrate an overall survival advantage in the pre chemotherapy setting. So, we shall see what the results are like,” posited Dr. Antonarakis.

In a recent interview, Emmanuel S. Antonarakis, M.D. discussed contributing factors to the recent American Cancer Society report about rising prostate cancer incidence and offered insights about the potential role of the radioligand agent 177Lu-PSMA-I&T for patients with mCRPC.

Welcome to Diagnostic Imaging’s Weekly Scan, which offers an opportunity to catch up on the most well-viewed radiology content of the past week.

 published research revealed that having PSMA PET/CT scans before salvage radiotherapy resulted 

in higher rates of survival and biomechanical recurrence-free survival at one, three and five years

neuroradiologist Tammie Benzinger discussed the utility of low-field MRI

 in facilitating appropriate triage and health equity for patients with suspected Alzheimer’s disease.

In a new digital breast tomosynthesis (DBT) study published in the 

78 percent malignancy rate when DBT images showed a combination of architectural distortion with highly suspicious m

Reading Room Podcast on emerging trends in theranostics for prostate cancer

, Jeremie Calais, M.D., Ph.D., discussed the potential of alpha-emitting therapies. Here is a clip from the podcast.

510(k) clearance for the NeedleVue LC1 ultrasound system

. While traditional ultrasound guidance for interventional procedures can be thwarted by complex calibration and reduced sensitivity, the multidirectional design with the NeedleVue LC1 Ultrasound System reportedly allows high-fidelity tracking from a variety of orientations.

Diagnostic Imaging's Weekly Scan is your chance to catch up on the latest radiology content, from new research and device news to the latest interviews with key opinion leaders in the field of radiology.

Diagnostic Imaging's Weekly Scan: August 11 — August 17 (Video Version)

Catch up on the latest news, research and insights in radiology with our Weekly Scan.

Magnetic resonance imaging (MRI) and prostate-specific membrane-antigen positron emission tomography (PSMA PET) both have limitations with respect to the detection of seminal vesicle invasion (SVI) in prostate cancer, noted Wayne Brisbane, M.D., in a recent interview.

“One of the issues is (MRI) is not super sensitive so if there's a small amount of seminal vesicle invasion, it might not be picked up, especially if the tumor volume is very small. But it's still important because we would risk adjust those patients and change their treatment paradigms,” noted Dr. Brisbane, an assistant professor of urology at the University of California-Los Angeles (UCLA). “ … With PSMA, there (are) other challenges. While molecular imaging is very easy to interpret, there is less spatial resolution between the prostate and the seminal vesicle so interpreting seminal vesicle invasion with PSMA and MRI can be challenging.”

However, in a recent lecture at the American Urological Association (AUA) Annual Meeting, Dr. Brisbane discussed key findings from a new study examining the use of the MRI-based artificial intelligence (AI) software Unfold AI (Avenda Health) for detecting SVI in patients with 

In an initial cohort of 147 men who underwent radical prostatectomy (with a 17 percent incidence of SVI), the researchers found that the AI software provided 92 percent sensitivity, 89 percent specificity and a 95 percent area under the receiver operating characteristic curve (AUC), 15 percent higher than the AUC for MRI alone (80 percent).

“(This) AI (software) was initially trained on (prostate) tumor volume but has found really impressive accuracy for predicting cancers coming out of the prostate or into the seminal vesicles,” noted Dr. Brisbane.

Study: PSMA PET/CT More Advantageous than MRI for Locoregional Staging of Prostate Cancer

Researchers Unveil PI-QUAL v2 for Prostate MRI Quality Assessments

Study Shows PET MRI Offers Better Detection of Localized Prostate Cancer than mpMRI

For more insights from Dr. Brisbane, watch the video below.

Wayne Brisbane, MD, discusses new research, presented at the American Urological Association (AUA) conference, which showed the benefits of the MRI-based Unfold AI software in detecting seminal vesicle invasion (SVI) in prostate cancer.

Study: MRI-Based AI Enhances Detection of Seminal Vesicle Invasion in Prostate Cancer

1. Brisbane W, Priester A, Mota SM, et al. Prediction of seminal vesicle invasion using artificial intelligence prostate cancer risk mapping. 

https://doi.org/10.1097/01.JU.0001109868.09667.98.20

 . Presented at the American Urological Association (AUA) Annual Meeting April 26-29, 2025, Las Vegas.

In a recent interview, Wayne Brisbane, M.D., discussed new research, presented at the American Urological Association (AUA) conference, which revealed a 15 percent higher AUC for an emerging AI software in detecting seminal vesicle invasion (SVI) in comparison to prostate MRI alone.

The positron emission tomography (PET) agent 18F-flotufolastat detected has a nearly 75 percent detection rate for recurrent prostate cancer in patients with prostate-specific antigen (PSA) levels of less than 1 ng/mL, according to research presented at the American Society for Radiation Oncology (ASTRO) conference.

In a recent interview, Bridget Koontz, M.D., the lead author of the post-hoc analysis from the SPOTLIGHT trial, said delayed renal clearance with 18F-flotufolastat (Posluma, Blue Earth Diagnostics) provides a unique advantage in this patient population in comparison to other imaging agents.

“Excretion into the bladder is slower (with 

F-flotufolastat) than some of the other agents out there … so you don't get sort of a cloud of urinary uptake that can blur … when we're trying to see what's happening in the prostate or in the prostate bed. That is a big advantage for low PSA patients, because they're less likely to have metastatic disease and, frankly, more likely in the post prostatectomy space to have prostate bed recurrence,” emphasized Dr. Koontz, the medical director of radiation oncology at AdventHealth Cancer Institute in Orlando, Fla.

F-Flotufolastat PET Imaging Changes Treatment in 89 Percent of Patients with Prostate Cancer Recurrence

Recurrent Prostate Cancer and Low PSA Levels: Can an Emerging PSMA PET Agent Have an Impact?

Optimal Timing and Frequency of Imaging Agents Used in the Detection and Characterization of Oligometastatic Prostate Cancer

In addition to an overall 69 percent detection rate in those with a pSA level of less than 1 ng/mL, the researchers found a 74 percent detection rate of PCa recurrence in patients with PSA levels between 0.5 ng/mL 

F-flotufolastat maintained high detection rates with even lower PSA levels, noting a 67 percent rate in those with PSA levels 0.3 ng/mL 

0.5 ng/mL and a 68 percent rate when PSA levels were 0.2 ng/mL 

(Editor's note: For additional content on prostate cancer imaging, visit 

For more insights from Dr. Koontz, watch the video below.

1. Koontz BF, Lowentritt B, Jani AB, et al. 

F-flotufolastat detection rates in the pelvis region for patients with prostate cancer recurrence after radical prostatectomy and PSA levels < 1 ng/mL: data from the phase 3 SPOTLIGHT study. Presented at the American Society for Radiation Oncology (ASTRO) 2024 Annual Meeting, September 29-October 2, 2024. Available at: 

https://www.astro.org/meetings-and-education/micro-sites/2024/annual-meeting

Bridget Koontz, MD discusses recent research at the ASTRO conference that shows benefits of the PET agent 18F-flotufolastat for detecting PCa recurrence in patients with low PSA levels.

Can 18F-Floutufolastat Bolster Detection of PCa Recurrence in Patients with Low PSA Levels After Radical Prostatectomy?

In a recent interview, Bridget Koontz, M.D., discussed the capability of the PET imaging agent 18F-flotufolastat for diagnosing post-prostatectomy recurrence of prostate cancer in patients with PSA values less than 1 ng/mL, based on research presented at the American Society for Radiation Oncology (ASTRO) conference.

Can 18F-Flotufolastat Bolster Detection of PCa Recurrence in Patients with Low PSA Levels After Radical Prostatectomy?

For African Americans with suspected prostate cancer (PCa) recurrence, the PET imaging agent 

F-flotufolastat (Posluma) provided a 93 percent patient-level detection rate (DR) that was six percent higher than that reported for other patients in the recent SPOTLIGHT trial.

F-flotufolastat had a 67 percent DR for African American patients with a prostate-specific antigen (PSA) level < 0.5 ng/mL and a 100 percent DR for those with a PSA level > 10 ng/mL in this patient population, according to the post-hoc analysis of the SPOTLIGHT trial that was recently published in 

In a recent interview, Soroush Rais-Bahrami, M.D., the lead author of the study, noted some small differences in regional detection rates between African Americans and other patients but said the findings were largely similar otherwise for the use of Posluma (Blue Earth Diagnostics) in diagnosing 

“The findings holding true and being validated in large part both with imaging and histopathologic confirmation really make this new FDA-approved PSMA PET imaging agent valid in all populations of men, specifically African Americans as well as non-African American men included in the study,” maintained Dr. Rais-Bahrami, a professor in the Departments of Urology and Radiology at the University of Alabama School of Medicine in Birmingham, Ala.

Dr. Rais-Bahrami also noted that African American men comprised 17 percent of the SPOTLIGHT study cohort, nearly double the rate of African American participation reported in oncology clinical trials from 2010 to 2021.

“This shows promise that clinical trials, specifically in the realm of cancer, can have a good diversity of enrollment in terms of subjects. One of the real elements of our focus in terms of performing clinical trials should be sure to encourage not only diversity of race … but also different areas regionally throughout the country and internationally as well as different sites of practice to really reach patients with different points of access, socioeconomic status, race, ethnicity and cultural factors that may play a large role in their overall medical and specifically, in this case, cancer care,” emphasized Dr. Rais-Bahrami.

Emerging Research at SNMMI Examines 18F-Flotufolastat in Managing Primary and Recurrent Prostate Cancer

Can Targeted PSMA PET/CT Guided Radiotherapy Have an Impact for Oligometastatic Prostate Cancer?

For more insights from Dr. Rais-Bahrami, watch the video below.

Soroush Rais-Bahrami, M.D., discusses a recent study that examined the use of 18F-flotufolastat (Posluma) for detecting prostate cancer recurrence in African American men.

Detecting PCa Recurrence in African Americans: Can 18F-Flotufolastat Have an Impact?

In a recent interview, Soroush Rais-Bahrami, M.D., discussed key findings from a post-hoc subgroup analysis of the SPOTLIGHT trial that examined the use of the PET imaging agent 18F-flotufolastat (Posluma) in African American men.

In separate studies presented at the recent 

, the positron emission tomography (PET) radiotracer 

F-flotufolastat demonstrated no urinary retention in patients with primary prostate cancer (PCa) and facilitated a 15 percent higher percentage of biochemical failure-free survival in comparison to conventional imaging for guided salvage radiotherapy in patients with recurrent PCa.

In one study comparing 18F-flotufolastat (Posluma, Blue Earth Diagnostics) and 

, researchers found that 18 percent of primary tumors located near the bladder in the 

Ga-PSMA-11-PET group (3/17) were obscured by radioactivity in the bladder in comparison no obscured tumors with 

F-flotufolastat (0/24). The study authors also reported a 27.4 percent rate of halo artifacts with the 

Ga-PSMA-11-PET cohort (17/62) in contrast to 4.8 percent (3/62) for those in the 

The researchers also emphasized that there was no ureter retention with 

F-flotufolastat in comparison to 21 percent (13/62) for men in the 

David Gauden, D.Phil, discussed these study results during an interview at the SNMMI conference.

“Their findings were clinically impactful in their opinion in that they had a much lower background radioactivity in the bladder (with 

F-flotufolastat) when they were evaluating the scans. (This) gave them more confidence in their diagnostic findings when they evaluated it on a multi-point scale of background (radiopharmaceutical) activity, leading them to believe that when you’re looking for local recurrences, using an agent with this lower bladder excretion could be clinically valuable in helping with the management of these patients,” noted Gauden, the chief executive officer for Blue Earth Diagnostics.

Study: 18F-Flotufolastat PET Imaging Changes Treatment in 89 Percent of Patients with Prostate Cancer Recurrence

Could Pluvicto Have a Role in Taxane-Naïve mCRPC?: an Interview with Oliver Sartor, MD

SNMMI: PSMA-18F DCFPyL Changes Treatment for PCa Recurrence in Significant Number of Patients with Low PSAs

In a separate study of 110 patients with biochemical recurrence of PCa after radical prostatectomy, researchers compared 

F-flotufolastat PET-guided salvage radiotherapy (SRT) to conventional SRT. Although the researchers conceded a lack of statistical significance, they found that the 

F-flotufolastat PET-guided group had 8 percent, 15 percent, and 21 percent higher rates of biochemical failure-free survival at one, two and three years, respectively, than those who had conventional SRT.

“Although it was a small study without a statistically significant finding, there were trends toward longer biochemical progression-free survival for the group where the radiotherapy was guided by PET imaging in addition to the standard field … ,” added Gauden.

For more insights from Mr. Gauden, watch the video below.

David Gsuden, D.Phil, discusses new research, presented at the SNMMI meeting, that examines use of 18F-flotufolastat in patients with prostate cancer.

Emerging Research at SNMMI Examines 18F-flotufolastat in Managing Primary and Recurrent Prostate Cancer

1. Rauscher I, Langbein T, Fuetterer CS, Weber W, Eiber M. Evaluation of qualitative and quantitative PET parameters in primary prostate cancer patients: double-match comparison of 18F-flotufolastat and 68Ga-PSMA-11-PET. Presented at the 2024 Society of Nuclear Medicine and Molecular Imaging Annual Meeting, June 8-11, Toronto, Canada. Available at: 

https://www.xcdsystem.com/snmmi/program/10OD8Tq/index.cfm

2. Rauscher I, Vogel MME, Gschwend J, Peeken JC, Eiber M. 18F-rhPSMA-7 and 18F-flotufolastat PET-guided salvage radiotherapy in recurrent prostate cancer. Presented at the 2024 Society of Nuclear Medicine and Molecular Imaging Annual Meeting, June 8-11, Toronto, Canada. Available at: 

In a recent interview at the SNMMI conference, David Gauden, D.Phil, discussed key findings from new research evaluating the use of the PET radiotracer 18F-flotufolastat in patients with primary prostate cancer (PCa) and men with biochemical recurrence of PCa. 

The radiopharmaceutical agent (177Lu)Lu-PSMA-617 (Pluvicto, Novartis) may be a viable option in the treatment of patients with taxane-naïve metastatic castration-resistant prostate cancer (mCRPC), according to emerging research findings presented at the 2024 Society of Nuclear Medicine and Molecular Imaging (SNMMI) Annual Meeting.

, Oliver Sartor, MD, said there are reimbursement challenges as well as mixed results with current androgen receptor pathway inhibitor (ARPI) treatment in this patient population.

In an interview at the SNMMI 2024 conference, Oliver Sartor, M.D. discussed key findings from new award-winning research evaluating the potential of Pluvicto in treating patients with taxane-naïve metastatic castration-resistant prostate cancer (mCRPC).

Disease Spotlight: Prostate Cancer

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