基于MET-RADS-P标准的全身磁共振成像在225Ac-PSMA放射性配体治疗转移性去势抵抗性前列腺癌中期疗效评估中的首次应用经验

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论证：以锕-225（225Ac）标记的前列腺特异性膜抗原（prostate-specific membrane antigen, PSMA）放射性配体治疗是一种用于转移性去势抵抗性前列腺癌的新型且前景广阔的治疗方法。全身磁共振成像（whole-body MRI，WB-MRI）是一种无创、无电离辐射的影像学检查方法，可获取骨及骨外转移灶的信息，并借助MET-RADS-P（METastasis Reporting And Data System for Prostate Cancer）体系实现结果的结构化呈现和对治疗反应的详细评估。然而，该评估体系尚未被普遍采用，其诊断效能仍需临床验证。

目的：评估基于MET-RADS-P标准的WB-MRI在225Ac-PSMA放射性配体治疗中期疗效评估中的应用价值；分析该方法的可重复性（同一阅片者一致性），并将影像学结果与前列腺特异性抗原（prostate-specific antigen, PSA）浓度变化进行比较。

方法：对转移性去势抵抗性前列腺癌患者进行两次WB-MRI检查：第一次在注射活度为6–12 MBq 的225Ac-PSMA-617之前完成，第二次在完成一次放射性配体治疗后1–2个月进行，并同步评估PSA浓度的动态变化。放射性配体治疗的前瞻性疗效评估采用WB-MRI的MET-RADS-P标准，并依据PCWG标准对PSA动态变化进行评估。通过同一名放射科医师在间隔6个月后对WB-MRI结果进行重复阅片，评估MET-RADS-P标准的可重复性。

结果：在完成研究的20例患者中，单次放射性配体治疗后，根据MET-RADS-P标准，有4例（20%）被判定为疾病进展，其中3例的影像学进展时间早于PSA浓度变化所提示的进展。超过一半的患者表现为不一致的反应，其中包括3例进展。在MET-RADS-P标准下，单向阳性反应与不同类型的不一致反应在PSA动态变化方面存在差异。在单向反应情况下，MET-RADS-P的综合评估与生化反应呈良好相关性。MET-RADS-P在主要反应评分类别及综合反应评估方面表现出极高的同一阅片者一致性。在次要反应评分类别中，其一致性为显著水平。

结论：在转移性去势抵抗性前列腺癌患者中，基于 MET-RADS-P标准的WB-MRI可较PSA浓度动态更早识别骨及骨外转移灶的疾病进展，并具有良好的同一阅片者一致性。有必要进一步研究MET-RADS-P标准在225Ac-PSMA放射性配体治疗中的预后意义。

作者简介

Tatiana P. Berezovskaia

A.F. Tsyb Medical Radiology Centre, National Medical Research Radiological Center

编辑信件的主要联系方式.
Email: berez@mrrc.obninsk.ru
ORCID iD: 0000-0002-3549-4499
SPIN 代码: 5837-3465

MD, Dr. Sci. (Medicine), Professor

俄罗斯联邦, Obninsk

Vladislav O. Ripp

A.F. Tsyb Medical Radiology Centre, National Medical Research Radiological Center

Email: rippnba@gmail.com
ORCID iD: 0000-0001-8970-4212
SPIN 代码: 3350-7131
俄罗斯联邦, Obninsk

Tatiana Yu. Kochetova

A.F. Tsyb Medical Radiology Centre, National Medical Research Radiological Center

Email: tat_mail@inbox.ru
ORCID iD: 0000-0002-7809-1059
SPIN 代码: 7542-9537
俄罗斯联邦, Obninsk

Valeriy V. Krylov

A.F. Tsyb Medical Radiology Centre, National Medical Research Radiological Center

Email: krylov.mrrc@mail.ru
ORCID iD: 0000-0001-6655-5592
SPIN 代码: 2555-1790

MD, Dr. Sci. (Medicine)

俄罗斯联邦, Obninsk

Sergei A. Ivanov

A.F. Tsyb Medical Radiology Centre, National Medical Research Radiological Center; Peoples' Friendship University of Russia

Email: ivanov.obninsk@mail.ru
ORCID iD: 0000-0001-7689-6032
SPIN 代码: 4264-5167

MD, Dr. Sci. (Medicine), corresponding member of the Russian Academy of Sciences

俄罗斯联邦, Obninsk; Moscow

Andrei D. Kaprin

Peoples' Friendship University of Russia; P.A. Herzen Moscow Research Institute of Oncology, National Medical Research Radiological Centre; National Medical Research Radiological Center

Email: mnioi@mail.ru
ORCID iD: 0000-0001-8784-8415
SPIN 代码: 1759-8101

MD, Dr. Sci. (Medicine), Professor, academician of the Russian Academy of Sciences

俄罗斯联邦, Moscow; Moscow; Obninsk

参考

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2. Fig. 1. Study design. RLT — radioligand therapy; 225Ac-PSMA — 225Ac-prostate-specific membrane antigen; MRI — magnetic resonance imaging; PSA — prostate-specific antigen; RPP — radiopharmaceutical preparation; MET-RADS-P (METastasis Reporting and Data System for Prostate Cancer) — reporting and classification system for prostate cancer metastases; PSWG (Prostate Cancer Working Group) — international expert group that developed standardised criteria for assessing disease progression and response to therapy in metastatic and castration-resistant prostate cancer.

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3. Fig. 2. Representative magnetic resonance imaging response to radioligand therapy. A 64-year-old patient with metastatic castration-resistant prostate cancer with multiple bone lesions. Results of whole-body magnetic resonance imaging at the level of the target lesion in the right pelvic bone (red arrows) before treatment (a, b, c) and 2 months after one course of radioligand therapy (d, e, f). There are no changes in the lesion on STIR images (a, d) and diffusion-weighted images (b, e); diffusion coefficient maps (c, f) show an increase in signal intensity from 0.67 × 10−3 to 1.6 × 10−3 mm2/s, which corresponds to the most likely response to treatment (RAC 1). A decrease in prostate-specific antigen concentration from 468 to 51 ng/ml was noted.

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4. Fig. 3. Representative magnetic resonance imaging of progression. A 71-year-old patient with metastatic castration-resistant prostate cancer with multiple bone lesions. Results of whole-body magnetic resonance imaging before treatment (a, c, e) and 1 month after one course of radioligand therapy (b, d, f): T1-weighted images at the level of the proximal femur (a, b) and pelvic bones (c, d); reconstruction of diffusion-weighted images of the chest using the maximum intensity projection method. Red arrows indicate areas with an increase in the size and number of metastatic foci, with the appearance of confluent lesions. An increase in the concentration of prostate-specific antigen from 103 to 212 ng/ml was noted.

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5. Fig. 4. Results of a single course of radioligand therapy with 225Ac-PSMA for each patient based on prostate-specific antigen concentration dynamics (as a percentage of nadir) and integral response variant in accordance with MET-RADS-P. The arrows indicate patients who had no progression in terms of prostate-specific antigen concentration at the time of assessment, but who did show progression in subsequent follow-up examinations. PSA — prostate-specific antigen; MET-RADS-P (METastasis Reporting and Data System for Prostate Cancer) — a system for reporting and classifying metastases in prostate cancer.

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6. Fig. 5. Range of changes in prostate-specific antigen concentration (% to nadir) after one course of radioligand therapy for different integral responses to treatment according to the MET-RADS-P system. NBRP — non-concordant response without progression, dominant pattern indicated in brackets; NPR — non-concordant response with progression; PSA — prostate-specific antigen; MET-RADS-P (METastasis Reporting and Data System for Prostate Cancer) — a system for reporting and classifying metastases in prostate cancer; RAC (Response Assessment Criteria) — criteria for assessing response to treatment.

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