{"id":881054,"date":"2026-09-05T15:20:30","date_gmt":"2026-09-05T15:20:30","guid":{"rendered":"https:\/\/www.newsbeep.com\/au\/881054\/"},"modified":"2026-09-05T15:20:30","modified_gmt":"2026-09-05T15:20:30","slug":"prostic26-surgical-psma-targeted-approaches-to-prostate-cancer","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/au\/881054\/","title":{"rendered":"ProsTIC26: Surgical PSMA-targeted Approaches to Prostate Cancer"},"content":{"rendered":"

(UroToday.com)\u00a0The 2026 ProsTIC annual meeting featured a PSMA imaging session and a presentation by Dr. Tobias Maurer discussing surgical PSMA-targeted approaches to prostate cancer. Dr. Maurer began his presentation by emphasizing that excellent preoperative molecular imaging does not necessarily translate into successful surgery. For example, in the following figure, a PSMA-avid pelvic lesion was clearly identifiable preoperatively but remained detectable on postoperative PSMA imaging:<\/p>\n


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\"image-0.jpg\"\u00a0<\/p>\n

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Identification of a lesion on preoperative imaging is only the first step. For surgery to be successful, imaging findings must be accurately communicated, anatomically localized, and translated into the operative field.<\/p>\n

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This challenge led to the development of the \u201cPelvic Rosetta Classification.\u201d Dr. Maurer drew an analogy to the Rosetta Stone, which enabled translation of Egyptian hieroglyphs. Similarly, differences in terminology and anatomic localization between imaging specialists and surgeons may create opportunities for miscommunication. Such miscommunication can potentially result in insufficient surgical treatment of prostate cancer. The Pelvic Rosetta Classification was therefore developed as an interdisciplinary, landmark-based pelvic lymph node map intended to improve communication between radiologists\/nuclear medicine physicians and surgeons. The framework incorporates a detailed definition of pelvic lymph node areas, exact radiographic delineation, correlation with the surgical view, and an interactive three-dimensional model:1<\/p>\n

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\"image-1.jpg\"<\/p>\n

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Dr. Maurer also placed radioguided surgery within the broader evolution of PSMA tracers for theranostics in prostate cancer. PSMA-targeted agents can be paired with different radionuclides according to their intended application. For therapy, PSMA-directed radioligand therapy uses beta (\u03b2\u2212) or alpha (\u03b1) emitters. For diagnostic imaging, positron-emitting tracers can be used for PET. Gamma-emitting agents provide another application of the same PSMA-targeting concept through SPECT imaging and, importantly for surgeons, radioguided surgery:<\/p>\n

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\"image-2.jpg\"<\/p>\n

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Thus, the PSMA target can connect three complementary applications: diagnostic PET imaging, radioligand therapy, and gamma-based SPECT\/radioguided surgery. The latter provides the opportunity to move molecular targeting from the preoperative scan directly into the operating room.<\/p>\n

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Dr. Maurer then reviewed the relatively short but rapidly evolving history of PSMA-radioguided surgery. The development of 68Ga-PSMA-11 at the German Cancer Research Center in Heidelberg dates to 2012. By 2014, 111In-PSMA-I&T had been developed as the first tracer for PSMA-radioguided surgery, and the first PSMA-radioguided surgical procedure was performed in April 2014. The technology subsequently evolved from open surgery to minimally invasive and robotic platforms. The first robotic PSMA-radioguided surgery procedure was performed in May 2018. By 2022, gamma counting had been integrated into a robotic surgical platform.<\/p>\n

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The evolution has continued across robotic systems, including the first HUGO-RAS PSMA-radioguided surgery procedure in 2025, followed in 2026 by the first single-port PSMA-radioguided surgery and the first Toumai PSMA-radioguided surgery procedures:<\/p>\n

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\"image-3.jpg\"<\/p>\n

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Regarding the basic workflow for PSMA-radioguided surgery, patients receive a preoperative intravenous injection of either 99mTc- or 111In-labeled PSMA ligands. Approximately one day later, metastatic lesions can be identified intraoperatively using a gamma probe:<\/p>\n

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\"image-4.jpg\"<\/p>\n

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The operative approach therefore uses the biologic signal generated by the PSMA-targeted radiotracer to complement the surgeon’s visual and tactile assessment. The gamma probe can interrogate tissue during surgery, allowing areas of increased radioactivity to be localized and removed. The resected specimen can also be evaluated ex vivo for radioactivity, providing an additional means of confirming that the suspected PSMA-positive tissue has been removed.<\/p>\n

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A critical technical step in moving PSMA-radioguided surgery into robotic surgery has been the miniaturization of gamma probes. Two examples include the DROP-IN gamma probe and the SENSEI\u00ae drop-in gamma probe:<\/p>\n

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\"image-5.jpg\"<\/p>\n

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Unlike traditional probes designed for open surgery, these devices can be introduced into the operative field and manipulated using robotic instruments. This allows the operating surgeon to directly control the detector and interrogate tissue while maintaining the advantages of minimally invasive robotic surgery.<\/p>\n

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Dr. Maurer then presented data from the prospective TRACE feasibility study (NCT03857113), which evaluated robotic PSMA-radioguided surgery using the DROP-IN gamma probe in 20 patients.2 The study demonstrated substantially greater radioactivity within tumor-positive tissue compared with background, both in vivo and ex vivo. Importantly, the tumor to background ratio was particularly favorable when specimens were assessed ex vivo.<\/p>\n

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The key diagnostic performance reported was:<\/p>\n


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\nSpecificity: 100% (53\/53)
\nSensitivity: 86% (19\/22)
\n <\/p>\n

\"image-6.jpg\"\u00a0<\/p>\n

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There are several potential clinical settings in which PSMA-radioguided surgery could be applied. One potential indication is primary prostate cancer with locoregional spread, where molecular imaging may identify regional disease that could be targeted during the initial operation. A second setting is locoregional lymph node recurrence. In this situation, patients who previously underwent definitive treatment may develop a limited number of PSMA-positive pelvic lymph nodes that are potentially amenable to salvage lymph node dissection.<\/p>\n

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A third potential indication is local recurrence following radical prostatectomy. These lesions may be anatomically challenging to identify because of their small size and altered postoperative anatomy. PSMA-directed radioguidance offers a strategy for translating molecular imaging findings into intraoperative localization:<\/p>\n

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\"image-7.jpg\"<\/p>\n

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In 2025, Knipper et al.3 evaluated early PSA responses among 553 patients after PSMA-radioguided surgery for recurrent prostate cancer. Of note, 56% had previously received salvage radiation therapy, and the median PSA prior to PSMA-radioguided surgery was 0.81 ng\/mL. Histologic evidence of prostate cancer was identified in 94.4% of patients. Early postoperative PSA responses demonstrated substantial heterogeneity following PSMA-radioguided surgery:<\/p>\n


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\n43% achieved a PSA <0.1 ng\/mL
\n14% had a PSA of 0.1 to <0.2 ng\/mL
\n43% had a PSA \u22650.2 ng\/mL\u00a0
\n <\/p>\n

The waterfall plot demonstrates the magnitude of PSA change following surgery without additional therapy and illustrates that a substantial proportion of patients achieved a marked biochemical response:<\/p>\n

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\"image-8.jpg\"<\/p>\n

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However, a meaningful subset of patients continue to have PSA \u22650.2 ng\/mL, highlighting the biologic heterogeneity of recurrent prostate cancer and the potential for disease outside the surgically treated PSMA-positive sites. In this study, PSA was assessed 4\u20138 weeks following surgery. The median therapy-free survival differed substantially according to this early postoperative PSA level (p < 0.0001):<\/p>\n


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\nPSA \u22650.2 ng\/mL: approximately 18 months
\nPSA 0.1 to <0.2 ng\/mL: approximately 43 months
\nPSA <0.1 ng\/mL: >5 years
\n <\/p>\n

\"image-9.jpg\"<\/p>\n

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Dr. Maurer also presented a retrospective analysis comparing PSMA-radioguided surgery with conventional salvage lymph node dissection.4 The analysis focused on patients with biochemical recurrence, PSA \u22644 ng\/mL, no ADT, and \u22642 lymph node metastases identified on choline or PSMA PET\/CT. Compared with conventional salvage lymph node dissection, PSMA-radioguided surgery was associated with improved biochemical recurrence free survival (p = 0.0452). The difference was even more pronounced for clinical recurrence free survival. Patients treated with PSMA-radioguided surgery demonstrated substantially better clinical recurrence-free survival compared with conventional salvage lymph node dissection (p = 0.0004):<\/p>\n

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\"image-10.jpg\"<\/p>\n

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Dr. Maurer concluded his presentation by looking beyond gamma-probe localization toward the integration of PSMA imaging with virtual three-dimensional and mixed-reality surgical models. The concept is to transform conventional cross-sectional imaging and PSMA PET findings into patient specific three-dimensional anatomic maps that integrate the location of suspected disease with the pelvic skeleton, vasculature, lymphatic anatomy, and surrounding structures. These models could then be viewed and manipulated in a mixed-reality environment to assist surgical planning and potentially intraoperative navigation (NICE-PSMA study; NCT07129551):<\/p>\n

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\"image-11.jpg\"<\/p>\n

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Presented by: Tobias Maurer, Martini-Klinik Prostate Cancer Center, University Hospital Hamburg Eppendorf, Hamburg, Germany<\/p>\n

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Written by: Zachary Klaassen, MD, MSc \u2013 Urologic Oncologist, Augusta, GA, @zklaassen_md on Twitter during\u00a0the 2026 ProsTIC Annual Meeting, Melbourne, Australia, Fri, Sept 3 \u2013 Sat, Sept 4, 2026. <\/a><\/p>\n

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References:<\/p>\n


\n
\nOrtner G, Hoderlein X, Barbato F, et al. The Pelvic Rosetta Classification Project: An Interdisciplinary Proposal for a Lymph Node Map of the Pelvis in Prostate Cancer. J Nucl Med. 2026 Jan 2;67(1):154-159.<\/a>
\nBerrens AC, Knipper S, Marra G, et al. State of the Art in Prostate-specific Membrane Antigen-targeted Surgery: A systematic review. Eur Urol Open Sci. 2023 Jun 16;54:43-55.
\nKnipper S, Lischewski F, Koehler D, et al. Biochemical response of <0.1 ng\/mL predicts therapy-free survival of prostate cancer patients following Prostate-specific Membrane Antigen-targeted salvage surgery. Eur Urol Oncol. 2025 Apr;8(2):270-277.
\nBravi CA, Knipper S, Heidenreich A, et al. Oncologic Outcomes of Template versus Radioguided Salvage Lymph Node Dissection for Node-only Recurrent Prostate Cancer on Prostate-specific Membrane Antigen Positron Emission Tomography scan: Results from a Multi-institutional Collaboration. Eur Urol Focus. 2025 Nov;11(6):921-925.<\/a> <\/p>\n","protected":false},"excerpt":{"rendered":"(UroToday.com)\u00a0The 2026 ProsTIC annual meeting featured a PSMA imaging session and a presentation by Dr. Tobias Maurer discussing…\n","protected":false},"author":2,"featured_media":881055,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[10],"tags":[64,63,137],"class_list":["post-881054","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health","tag-au","tag-australia","tag-health"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/posts\/881054","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/comments?post=881054"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/posts\/881054\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/media\/881055"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/media?parent=881054"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/categories?post=881054"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/tags?post=881054"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}