Prostate-Specific Membrane Antigen–Targeted Radioguided Pelvic Lymph Node Dissection in Newly Diagnosed Prostate Cancer Patients with a Suspicion of Locoregional Lymph Node Metastases: The DETECT Trial

Prostate-specific membrane antigen (PSMA)–targeted radioguided surgery (RGS) aims to optimize the peroperative detection and removal of PSMA-avid lymph node (LN) metastases (LNMs) and has been described in patients with recurrent prostate cancer (PCa). In newly diagnosed PCa patients undergoing pelvic LN dissections, PSMA RGS could guide the urologist toward PSMA-expressing LNMs as identified on preoperative ¹⁸F-PSMA PET/CT imaging. The objective was to evaluate the safety and feasibility of ¹¹¹In-PSMA RGS in primary PCa patients with one or more suggestive LNs on preoperative ¹⁸F-PSMA PET/CT. Methods: This prospective, phase I/II study included 20 newly diagnosed PCa patients with at least 1 suggestive LN on preoperative ¹⁸F-PSMA PET/CT. PSMA RGS was performed 24 h after ¹¹¹In-PSMA-I&T administration, and postoperative ¹⁸F-PSMA PET/CT was performed to verify successful removal of the suggestive lesions. The primary endpoint was determination of the safety and feasibility of ¹¹¹In-PSMA RGS. Safety was assessed by monitoring adverse events. Feasibility was described as the possibility to peroperatively detect suggestive LNs as identified on preoperative imaging. Secondary outcomes included the accuracy of ¹¹¹In-PSMA RGS compared with histopathology, tumor- and lesion-to-background ratios, and biochemical recurrence. Results: No tracer-related adverse events were reported. In 20 patients, 43 of 49 (88%) ¹⁸F-PSMA PET–suggestive lesions were successfully removed. ¹¹¹In-PSMA RGS facilitated peroperative identification and resection of 29 of 49 (59%) RGS-target lesions, of which 28 (97%) contained LNMs. Another 14 of 49 (29%) resected LNs were not detected with ¹¹¹In-PSMA RGS, of which 2 contained metastases. Conclusion:¹¹¹In-PSMA RGS is a safe and feasible procedure that allows peroperative detection of ¹⁸F-PSMA PET/CT–suggestive lesions in newly diagnosed PCa patients. The use of a radioactive PSMA tracer and a detection device (γ-probe) during surgery helps in identifying LNs that were suggestive of PCa metastases on the ¹⁸F-PSMA PET/CT before surgery and thus may improve the peroperative identification and removal of these LNs.