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Complementary Role of PSMA PET/CT in Detecting Clinically Significant Prostate Cancer Recurrence After Focal Therapy
Anthony Zhang, BS, Nishan Sohoni, BS, MS, Andrea Lopez-Sanmiguel, MD, Preston C, Sprenkle, MD.
Yale University School of Medicine, New Haven, CT, USA.

Introduction: Post-focal therapy (FT) surveillance for localized prostate cancer relies on PSA and multiparametric MRI, but post-ablative changes may limit MRI reliability. PSMA PET/CT may improve visualization of residual or recurrent clinically significant prostate cancer (csPCa; Gleason Grade Group [GG]≥2), though comparative data following FT remains limited. We evaluated recurrence detection patterns of MRI and PSMA PET/CT for 2 years after subtotal FT. Methods: We retrospectively reviewed men undergoing primary subtotal FT (cryoablation, transurethral ultrasound ablation (TULSA), or irreversible electroporation (IRE)) from 2014-2025 with post-treatment biopsy within 2 years. MRI positivity was defined as PI-RADS 4-5, and PSMA PET/CT positivity as focal intraprostatic uptake suspicious for recurrence. The primary endpoint was biopsy-proven csPCa (GG≥2). Diagnostic performance metrics were calculated using biopsy as the reference standard. Results:Among 76 post-FT biopsies, 24 (31.6%) demonstrated csPCa recurrence. MRI independently identified 9 of 24 (37.5%) recurrences (sensitivity), with an overall specificity of 81.6%. PSMA PET/CT was performed in 17 patients and was positive in 13 (76.5%). Within this subset, PSMA PET/CT detected all biopsy-proven recurrences. Among PET-positive cases, 9 cases corresponded to MRI-positive lesions, while 4 additional recurrences were identified in MRI-negative regions. Conclusions: In this single-institution series, MRI demonstrated modest sensitivity for detecting recurrence following FT despite routine use. PSMA PET/CT identified additional clinically significant disease not detected by MRI within a selectively imaged subset. These findings support a complementary role for PSMA PET/CT in post-FT surveillance. Prospective and larger form studies are needed to define optimal timing and integration alongside MRI.
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