In recent years, prostate-specific membrane antigen (PSMA) molecular imaging technology has demonstrated significant value in the diagnosis and treatment of prostate cancer. It has improved the accuracy of clinical staging, supported multimodal treatment decision-making, and facilitated the development of precision medicine through novel radioligand therapies. At the recent EAU Congress, UroStream invited Professor Xuefeng Qiu from Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School,Nanjing University, to share insights into his team’s research on PSMA PET/CT for predicting biochemical recurrence (BCR), the impact of tumor heterogeneity, and the clinical experience at Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School，Nanjing University.UroStream:Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School,Nanjing University had several studies selected for presentation at this year’s EAU Congress. One of them (Abstract No. P588) focused on using ⁶⁸Ga-PSMA-11 PET/CT imaging heterogeneity to predict biochemical recurrence. Could you first summarize the key findings of this study?
Professor Xuefeng Qiu: In recent years, PSMA-PET/CT has drawn increasing attention in the field of prostate cancer diagnosis and treatment, with a growing number of studies exploring its applications. The European Association of Urology (EAU) has also issued annual updates to its clinical guidelines, further endorsing the use of PSMA-PET/CT in prostate cancer diagnostics.
Our research stemmed from a fundamental characteristic of tumors—especially prostate cancer—which is their high degree of heterogeneity. Traditional diagnostic tools such as prostate-specific antigen (PSA) testing, computed tomography (CT), and magnetic resonance imaging (MRI) often fall short in accurately capturing this heterogeneity. Previous studies have shown that tumor heterogeneity revealed by PSMA-PET/CT is closely linked to prognosis and treatment response in patients with metastatic castration-resistant prostate cancer (mCRPC).
This prompted us to ask: Could the tumor heterogeneity observed on PSMA-PET/CT also be associated with prognosis in localized prostate cancer?
To explore this, we conducted a retrospective study. Our findings suggest that when the primary tumor shows pronounced heterogeneity on PSMA-PET/CT, this is significantly associated with various oncological outcomes—including higher rates of positive surgical margins, increased risk of lymph node metastasis, and faster biochemical recurrence.
These results indicate that PSMA-PET/CT has promising potential not only for predicting biochemical recurrence but also for anticipating adverse pathological features. We believe it will play an increasingly important role in future clinical decision-making.
UroStream: This study touches on two of the most prominent topics in the field—PSMA-targeted diagnostics and PET/CT imaging. What is your perspective on the recent advances in PSMA-based diagnosis and therapy, and the potential impact of PSMA heterogeneity?
Professor Xuefeng Qiu: The popularity of PSMA-PET/CT has continued to grow in recent years, and its clinical applications are expanding rapidly. At present, PSMA-PET/CT is recommended for patients with biochemical recurrence (BCR), including those who have previously undergone radical prostatectomy or radiotherapy. The reason for this recommendation lies in the complexity of the “biochemical recurrence” concept.
Unlike the straightforward concept of visible tumor recurrence that patients typically understand, BCR refers to a rise in tumor markers—such as PSA—despite the absence of clinical symptoms or detectable lesions on conventional imaging. For example, according to the EAU guidelines, BCR after prostatectomy is defined as a detectable PSA level 4–8 weeks post-surgery or a confirmed rise to ≥0.4 ng/ml after having previously dropped below detection limits. For patients post-radiotherapy, BCR is defined as a PSA increase of more than 2 ng/ml above the nadir.
This “invisible” form of recurrence often leaves patients confused and anxious, wondering where the cancer could be hiding. The core issue is the limited sensitivity of traditional imaging tools. Previously, therapeutic options for BCR were relatively limited—radiotherapy being the primary intervention. However, conventional radiotherapy was imprecise, often delivered broadly without targeting, leading to suboptimal outcomes and considerable side effects.
The advent of PSMA-PET/CT has significantly improved diagnostic sensitivity, enabling the detection of lesions that were previously undetectable. This breakthrough has transformed the management paradigm for BCR. Now that recurrent lesions can be visualized clearly, physicians can tailor treatment strategies more precisely—whether palliative or salvage therapies—thus expanding the range of available options and offering new survival benefits to patients.
Furthermore, we’ve found that PSMA-PET/CT plays a critical role in addressing tumor heterogeneity. As previously mentioned, tumor heterogeneity is closely associated with poor pathological outcomes and unfavorable survival in prostate cancer. Leveraging the insights provided by this imaging modality, clinicians can incorporate heterogeneity assessments into personalized treatment planning. As a non-invasive and highly effective tool, PSMA-PET/CT holds great potential to guide precision therapy tailored to individual patient profiles.
UroStream: PSMA-PET/CT has greatly improved the detection rate of micrometastatic lesions. Could you share your team’s clinical experience at Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School，Nanjing University regarding its applications, such as in staging, follow-up, or prognostication?
Professor Xuefeng Qiu: I’d be happy to share some of our clinical insights into the diverse applications of PSMA-PET/CT at Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School，Nanjing University.
First, PSMA-PET/CT is a powerful tool for accurately evaluating patients with biochemical recurrence. As discussed earlier, a considerable proportion of BCR cases detected by PSMA-PET/CT may involve true clinical recurrence or oligometastases. For these patients, we can offer more effective multimodal treatment strategies, which increases their chances of benefiting from therapeutic interventions beyond standard care.
Second, PSMA-PET/CT enables more precise clinical staging. Current guidelines recommend a combination of bone scans, MRI, and CT for comprehensive assessment. However, these modalities often fall short in identifying small or limited metastases. PSMA-PET/CT, with its superior sensitivity, allows for a more accurate assessment of disease extent and can guide comprehensive treatment plans, such as the “tripartite” strategy—addressing the primary tumor, metastatic sites, and systemic disease concurrently.
Third, PSMA-PET/CT is invaluable in managing complex cases and in patients with metastatic castration-resistant prostate cancer (mCRPC). At the mCRPC stage, tumor heterogeneity—both molecular and anatomical—is even more pronounced, posing significant challenges for precise assessment. While ctDNA-based molecular testing is available, it is costly, time-consuming, and invasive (requiring tissue samples). In contrast, PSMA-PET/CT can provide molecular-level insights non-invasively, aiding in the selection of targeted therapies. This is particularly relevant for patients with low PSA sensitivity at this stage, where PSA-based monitoring is unreliable. PSMA-PET/CT offers critical guidance for both treatment planning and response evaluation.
In summary, PSMA-PET/CT is transforming diagnostic evaluation. Both the EAU and earlier ASCO GU meetings have highlighted new radionuclide therapies targeting PSMA, such as lutetium-177 and actinium-225. These emerging therapies represent a promising shift in the management of advanced prostate cancer, potentially challenging the dominance of traditional chemotherapy and next-generation hormonal therapies. They may well mark the beginning of a new era in treatment.
UroStream: Returning to your current study—if ⁶⁸Ga-PSMA-11 PET/CT can predict patients at high risk for biochemical recurrence, could these patients benefit from early intervention, such as novel hormonal therapy (NHT) or radiotherapy? Could you share your clinical experience in managing high-risk localized prostate cancer?
Professor Xuefeng Qiu: Selecting appropriate postoperative treatment for patients at high risk of recurrence is a hot topic in prostate cancer care. Should we pursue early adjuvant therapy, or wait until BCR occurs and then implement salvage treatment? Our study, utilizing a non-invasive molecular imaging tool—PSMA-PET/CT—offers some insight into this question.
By integrating preoperative PSMA-PET/CT imaging with postoperative PSA kinetics, pathological findings, and assessments of tumor heterogeneity, we can stratify patients more effectively. For those with high-risk features who are in good physical condition, recover quickly, and are tolerant of side effects, adjuvant radiotherapy combined with hormonal therapy is a reasonable option. On the other hand, for patients evaluated as low-risk for BCR based on PSMA-PET/CT and other factors, we prefer an observational approach—monitoring closely and reserving salvage treatment until clear signs of recurrence emerge.
Today’s tools and methodologies are steering prostate cancer management toward greater personalization. The inherent heterogeneity of the disease means each patient is unique, with different tumor characteristics, physical conditions, and treatment goals. As I often tell my patients, “There is no single best treatment—only the treatment that suits you best.”
Professor Xuefeng Qiu
Associate Chief Physician, Department of Urology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School，Nanjing University
- Associate Professor, Nanjing University Medical School
- Doctor of Medicine (MD, PhD)
- Master’s Supervisor (Nanjing University, Nanjing Medical University, Nanjing University of Chinese Medicine)
- Postdoctoral Fellow, UCSF (University of California, San Francisco) and School of Life Sciences, Nanjing University
- Selected Scholar, Jiangsu Province “333 High-Level Talent Training Program”
- Selected Scholar, Nanjing Youth Talent Development Program
- Executive Secretary, Medical Robotics Committee, Jiangsu Medical Doctors Association
