The Role of PSMA-Radioligand and Magnetic Resonance Imaging in Patients with Prostate Cancer Biochemical Recurrence

A significant proportion of men with prostate cancer will experience biochemical recurrence (BCR), which is characterized by an elevation in prostate-specific antigen (PSA) levels after receiving treatment with curative intent. Imaging plays an important role in the management of patients with BCR. It can help identify sites of recurrence to determine the most appropriate management strategies, ranging from salvage treatment for local recurrences to systemic treatments for those with advanced, distant disease. PET/CT with prostate-specific membrane antigen (PSMA)-radioligands is the most sensitive method for the detection of prostate cancer recurrence, with significantly higher cancer detection rates compared to conventional imaging techniques such as bone scan and computed tomography, even at lower PSA levels. Nevertheless, interpretation of PSMA PET/CT images can be challenging, particularly for the evaluation of local recurrence due to urinary activity that can mimic or mask the presence of cancer. Furthermore, some prostate cancers may not express PSMA and have false negative results. Multiparametric prostate MRI is an excellent method for the evaluation of local recurrence and can overcome some of the limitations of PSMA PET/CT. In this review, we discuss the role of imaging in managing patients with prostate cancer BCR and describe the potential benefits of MRI in the PSMA-radioligand imaging era, emphasizing the assessment of local recurrence.