cfDNA Fragmentation Patterns Correlates with Tumor Burden Measured via PSMA PET/CT Volumetric Parameters in Patients with Biochemical Recurrence of Prostate Cancer

cfDNA Fragmentation Patterns Correlates with Tumor Burden Measured via PSMA PET/CT Volumetric Parameters in Patients with Biochemical Recurrence of Prostate Cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article cfDNA Fragmentation Patterns Correlates with Tumor Burden Measured via PSMA PET/CT Volumetric Parameters in Patients with Biochemical Recurrence of Prostate Cancer Gary Amseian, Marcel Figueras, Joel Mases, Lourdes Mengual, Maria-Jose Ribal, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4905783/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Dec, 2024 Read the published version in EJNMMI Research → Version 1 posted 5 You are reading this latest preprint version Abstract Background Prostate cancer recurrence following primary treatment poses a significant clinical challenge, particularly when detected through biochemical recurrence at low PSA levels. Conventional imaging modalities often fail to localize the disease at this early stage. PSMA PET has demonstrated superior sensitivity in detecting recurrent lesions, even in patients with low PSA. Concurrently, liquid biopsy, through analysis of cell-free DNA (cfDNA), offers a minimally invasive approach for monitoring disease. There is scarce evidence about the association between liquid biopsy and PSMA PET/CT findings. This study aimed to assess the correlation between liquid biopsy and tumor burden assessed by PSMA PET/CT in early recurring prostate cancer patients. Results PSMA PET/CT and liquid biopsies of 32 patients in biochemical recurrence were analyzed. 12 patients (37.5%) had no PSMA PET-measurable disease. Four patients (12.5%) presented local recurrence, seven (21.9%) had recurrence in pelvic lymph nodes, one of whom also had local recurrence. Nine patients (28.1%) presented metastatic recurrence, with or without local or nodal recurrence. PSA levels correlated with molecular imaging data ( p < 0.05), including wbPSMA-TV40, wbTL-PSMA40, wbSUVmean and wbSUVmax. The mean cfDNA fragment size fraction was inversely correlated with tumour burden measured with wbPSMA-TV, with a Spearman correlation coefficient of -0.451 and a p-value of 0.009. No correlation was found between cfDNA concentration and PET-PSMA data. Conclusion This prospective study demonstrated a statistically significant negative correlation between cfDNA fragmentation patterns and PSMA PET/CT volumetric parameters in localized prostate cancer patients with early biochemical recurrence. These findings underscore the potential of liquid biopsy as a biomarker and a complementary tool to PSMA PET/CT to assess disease progression during the follow-up of these patients. prostate cancer biochemical recurrence PSMA PET liquid biopsy Figures Figure 1 Figure 2 Figure 3 Introduction Prostate cancer (PCa) is the second most common cancer in men worldwide and the most frequent malignancy in Europe and the USA. It had an estimated global mortality of 375,000 in 2020 ( 1 ). Serum prostate-specific antigen (PSA) quantification, imaging techniques such as magnetic resonance imaging (MRI), and prostate biopsy are the current tools for PCa diagnosis ( 2 ). Usually, treatment of localized PCa patients includes a local approach like radical prostatectomy (RP) or radiotherapy ( 3 ). After treatment, serial PSA quantification is used to detect biochemical recurrence (BR). Overall, within two years of RP, approximately 14% of overall PCa patients experience BR ( 4 ), and this percentage is higher in patients with high-risk factors ( 5 , 6 ). Despite BR being detected, not all patients present detectable disease recurrence with current imaging techniques such as computed tomography (CT) and bone scintigraphy. Prostate-specific membrane antigen (PSMA) is highly expressed in PCa cells,( 7 ) making it an excellent target for diagnostic imaging. PSMA PET has demonstrated superior diagnostic accuracy and a greater impact on management decisions( 8 ) compared with conventional methods. Particularly during the early stages of BR, both anatomical imaging and bone scintigraphy frequently fail to accurately identify the site of relapse, while PSMA PET has proven useful in detecting recurrent lesions, even in patients with low PSA levels ( 9 , 10 ). PSMA PET can pinpoint the exact location of recurrence, enabling localized treatments such as targeted radiotherapy or salvage surgery ( 11 ). Thus, PSMA PET has emerged as the preferred imaging tool for diagnosis in the setting of BR after radiotherapy treatment( 12 – 14 ) and is recommended after RP, as indicated in the EAU guidelines ( 15 , 16 ), especially at low PSA levels ( 17 , 18 ). Assessing tumour volume (denoted as PSMA-TV) is advised during PSMA PET interpretation, as growing evidence suggests that it may be a prognostic factor of overall survival ( 19 ). Alternatively, liquid biopsy techniques to study molecular biomarkers in several cancer types, including PCa are gaining considerable importance. Liquid biopsy analysis provides cancer-specific information from a simple and minimally invasive blood extraction that can be repeatedly obtained from patients, making it an ideal approach for disease monitoring, during both diagnosis and follow-up ( 20 ). One of the components found in liquid biopsy samples is cell-free DNA (cfDNA), which consists of highly fragmented nucleic acids secreted from apoptotic cells, both healthy and cancer cells. High cfDNA levels are associated with poor prognosis in different urologic tumours, including PCa ( 21 – 23 ). It seems that cfDNA secreted by tumour cells is shorter than that originating from non-malignant cells ( 24 – 26 ). Moreover, cfDNA fragmentation patterns can provide diagnostic and prognostic value. There is scarce evidence about the association between liquid biopsy and PSMA PET/CT findings ( 27 – 29 ), however, there are promising results. To the best of our knowledge, the correlation between PSMA PET and liquid biopsy in early recurring PCa patients has not been studied yet. Therefore, this study aimed to assess the correlation between cfDNA concentration, and mean cfDNA fragment fraction and tumour burden assessed by PSMA PET in the setting of BR PCa patients. Material and methods Patients Patients referred to the Nuclear Medicine department for PSMA PET/CT in the setting of BR of PCa between February 2022 and February 2023 were prospectively included in the study. None of the patients included had other active neoplasms. All patients had previously undergone RP. BR was defined as PSA > 0.4 ng/ml and rising as per EAU guidelines ( 30 , 31 ). As a PSMA PET/CT performance criterion is PSA > 0.2 ng/ml, we also included 10 patients with PSA levels ranging from 0.2 to 0.4 ng/ml. The clinical and pathological characteristics of these patients are shown in Table 1. All BR patients were re-staged with PSMA PET/CT scans using [ 18 F]F-DCFPyL in 29 patients (91%) or [ 68 Ga]Ga-PMSA-11 in three (9%). The median PSA level during recurrence was 0.74 ng/mL (IQR 0.94). One 10 mL EDTA tube of peripheral blood was collected when PET PSMA was performed due to BR and stored at 4⁰C until processed within the following four hours. Peripheral blood was then used to isolate cfDNA. PSMA PET/CT acquisition protocol PSMA PET/CT was performed using a Biograph mCT TrueV PET/CT hybrid device (Siemens, Germany), with low-dose CT for attenuation correction and image fusion. The radiotracers used were [ 18 F]F-DCFPyL and [ 68 Ga]Ga-PSMA-11, at doses of 4 and 2 MBq/Kg, respectively. PSMA PET/CT imaging was acquired from the skull base to the proximal third of the thigh with arms raised above the head, 60 min after radiotracer injection for [ 68 Ga]Ga-PSMA-11 and 90 minutes p.i. for fluorine tracer, and at 2.5 min per bed. PET data reconstruction was performed using a standard iterative algorithm from CT records. Image analysis and interpretation PSMA PET/CT images were assessed using a workstation (syngo.PET&CT Oncology VA20A, Siemens Healthineers AG, Germany) by a physician in training and a senior nuclear medicine specialist experienced in PSMA PET/CT. Any discrepancies were resolved by consensus. Pathological findings were defined following the Second Version of the Prostate Cancer Molecular Imaging Standardized Evaluation Framework Including Response Evaluation for Clinical Trials (PROMISEv2) criteria ( 30 ). Spherical or ellipsoidal regions of interest were placed over all pathological uptakes on PSMA PET/CT images, ensuring that the entire lesion was enclosed in axial, sagittal, and coronal projections. Standarized uptake values (SUVs) (SUVmax and SUVmean) were automatically calculated based on measured activity concentration (Bq/mL) multiplied by patient weight (kg) and normalized to injected activity (Bq). To obtain PSMA-derived tumour volume values (PSMA-TV), the contouring margins of each lesion were delineated by a threshold of 40% SUVmax using an SUV-based automated contouring program (Syngo.via, Siemens Healthineers, Germany). Volumetric whole-body analysis was performed to assess the PSMA tumour burden, including all lesions: local recurrence, lymph nodes, and distant metastases, which together constitute the whole-body PSMA tumour burden. The sum of the PSMA-TV of each lesion was defined as whole-body (wb) PSMA-TV (wbPSMA-TV), which was recorded and calculated for the entire disease. To report the extent and location of recurrence lesions in PSMA PET images, PROMISEv2 criteria were used. Patients were classified into subgroups based on the presence of local, nodal, and/or metastatic disease according to a combination of the following categories: no local tumour (T0), local recurrence (Tr), with no positive pelvic lymph nodes (N0), lymph node metastases in a single pelvic lymph node region (N1), lymph node metastases in more than one pelvic lymph node region (N2), no distant metastases (M0), lesions in distant lymph node regions (M1a), bone metastases (M1b), and metastases in other sites (M1c). cfDNA isolation and quantification To separate plasma, blood samples were centrifuged at 3500 rpm for 15 min at 4⁰C, followed by plasma centrifugation at 16000 x g for 10 min at 4⁰C to remove any remaining cells. Plasma samples were then stored at -80⁰C until cfDNA extraction. cfDNA was extracted from 1.5 to 4 mL of plasma (depending on availability) using the QIAamp Circulating Nucleic Acid Kit (Qiagen, Hilden, Germany), according to the manufacturer’s instructions. Plasma cfDNA concentration was obtained using the Quant-it PicoGreen dsDNA Assay kit. The mean cfDNA fragment size fraction was evaluated using the Agilent 2200 TapeStation System. The average size fraction from short fragments (100–250 bp) was calculated from the electropherogram. Statistical Analysis PSMA PET/CT data were compared against cfDNA levels and mean fragmentation patterns in the cohort studied using Spearman’s rank correlation coefficient or χ² test depending on the variable’s nature. Moreover, PSMA PET/CT and liquid biopsy data were correlated with clinicopathological variables from each patient including PSA levels at diagnosis and at the time of BR, ISUP (International Society for Urological Pathology) score, pathological stage, affected margins, regional lymph node metastasis, among others, using Spearman’s rank correlation coefficient or χ² test depending on the variable’s nature. Statistical significance was established at a p-value of 0.05. All analyses were carried out with the SPSS software package (IMB SPSS Statistics 25). All participants provided written informed consent (HCB/2013/8753) before being included in this study. The study methodology conformed to the standard set by the Declaration of Helsinki and was approved by the Clinical Research Ethics Committee of the Hospital Clínic Barcelona (HCB/2022/0542). Results Of the 32 patients with BR included, 12 (37.5%) had no PSMA PET/CT-measurable disease. Four patients (12.5%) presented local recurrence and seven (21.9%) had a recurrence in the pelvic lymph nodes, one of whom also had local recurrence. Nine patients (28.1%) presented metastatic recurrence, with or without local or nodal recurrence (Figure 1). The recurrence sites with their corresponding staging according to PROMISEv2 criteria are detailed in Table 2. PSA levels correlated with molecular imaging data, including wbPSMA-TV40 (Spearman’s correlation coefficient (SCC)=.489; p=0.005), wbTL-PSMA40 (SCC=.449; p=0.01), wbSUVmean (SCC=.418; p=0.017) and wbSUVmax (SCC=.428; p=0.014) (Fig. 2). PSMA PET/CT parameters—such as wbPSMA-TV, wbTL-PSMA40, wbTL-PSMA40, wbSUVmax and wbSUVmean— and liquid biopsy parameters—such as cfDNA concentration and mean cfDNA fragmentation patterns—in recurrent patients based on disease extension are shown in Table 3. The mean cfDNA fragment size fraction was inversely correlated with tumour burden measured via wbPSMA-TV, with an SCC of -0.451 and a p-value of 0.009 (Figure 3). No correlation was found between cfDNA concentration and PSMA PET/CT data. Discussion After local treatment, between 25% and 50% of PCa patients will develop BR and be at an increased risk of developing metastasis. Imaging can help to determine whether the recurrence is local or distant; however, its performance is PSA-dependent. Liquid biopsy may be useful in combination with PSMA PET to improve metastasis assessment. We assessed the correlation between cfDNA concentration and mean cfDNA fragment size fraction and image-derived volumetric parameters from PSMA PET/CT in a cohort of PCa patients with RP at the time of BR. To our knowledge, this is the first study focused on PSMA PET and liquid biopsy in early recurring PCa patients. We found a statistically significant negative correlation between wbPSMA-TV and mean cfDNA fragment size fraction. Short cfDNA fragments are associated with apoptosis of cancerous cells, implying that these patients might have a higher tumour burden and a higher risk of progression to metastatic disease. This result is consistent with other studies conducted to date in different settings ( 27 – 29 , 31 ). Chen et al. compared cfDNA in healthy controls (n = 34), patients with localized PCa (n = 112), and patients with metastatic castration-resistant prostate cancer (mCRPC) (n = 122). They found that localized PCa patients had a shorter average cfDNA fragment size when compared with controls ( 26 ). Similar correlations have been observed in other malignancies. In a previous study on stage III-IV non-small cell lung cancer (NSCLC) patients (n = 53) ( 29 ); cfDNA fragmentation correlated with fludeoxyglucose-18 (FDG) PET/CT parameters from primary tumour, extrapulmonary disease and whole-body disease. In this sense, mean cfDNA fragmentation patterns in combination with PSMA PET parameters might be useful to detect patients with a high risk of progression. On the other hand, we found no correlation between cfDNA levels and volumetric parameters from PSMA PET/CT. In addition, there were no differences in cfDNA levels between patients with different recurrence sites classified using PSMA PET. Kluge et al. compared the correlation of liquid biopsy data and PSMA PET between patients with hormone-sensitive prostate cancer (HSPC) (n = 74) and mCRPC (n = 74). They found that cfDNA levels were weakly correlated with PSMA-TV in the mCRPC group but not in the HSPC group ( 31 ). Chen et al. observed that plasma cfDNA concentrations were significantly elevated in patients with mCRPC but not in patients with localized disease. Along that same line, a study from González de Aledo-Castillo et al. on NSCLC found a positive correlation between cfDNA concentration and extrapulmonary FDG PET/CT volumetric parameters, while no association was found between cfDNA concentration and FDG PET/CT parameters from local disease. The previously published results indicated a stronger correlation in advanced disease, which account for the absence of correlation in our series. It is important to note that, as illustrated in the cohort studied in this work, BR is a highly heterogeneous entity that includes patients with local, nodal or oligometastatic extension. Our cohort included patients with early BR, with low tumour burden. Regarding liquid biopsy and PSMA PET parameters, this group of patients might behave similarly to those with localized disease in previously described studies—which also found no significant differences in cfDNA concentration. Furthermore, it could differ from cohorts with more advanced stages of the disease, specifically in patients with mCRPC, in whom higher levels of cfDNA were found. Considering this, cfDNA concentration may identify patients with high tumour burden but it might present limitations when distinguishing between healthy individuals and patients with localized PCa or early BR. PSMA PET/CT may produce false negatives in patients with micrometastases and oligometastases. Studies by Budaus et al. ( 32 ) and Van Leeuwen et al. ( 33 ) comparing presurgical PSMA PET/CT with histopathological findings of removed lymph nodes reported a 33% and 64% sensitivity for lymph node metastasis detection, respectively. Both studies found that false-negative lesions were significantly lower than true-positives. This shows that lesion size impacts PSMA PET detection, which is a crucial matter in early recurrence with a small tumour burden. This could have altered the correlation between PSMA PET/CT and liquid biopsy parameters, especially considering that cfDNA is a non-tumour-specific marker that, despite its utility and availability, can be affected by other factors, such as tissue damage or chronic diseases. Despite this, we found a statistically significant correlation between liquid biopsy and PSMA PET/CT, consistent with previous studies on the subject. To the best of our knowledge, this is the first work to focus specifically on patients with BR. We acknowledge the limitations of our study, mainly the limited sample size that might have affected the statistical analysis, thus hindering the conclusions. However, given the difficulty of detecting disease in patients with early BR of PCa, we believe cfDNA fragmentation could serve as a biomarker to identify oligometastatic patients with low disease burden during follow-up. Further research with larger cohorts is warranted to validate these results and explore the clinical utility of cfDNA fragmentation analysis in this context. Conclusion This prospective study demonstrated a statistically significant negative correlation between cfDNA fragmentation patterns and PSMA PET/CT volumetric parameters in localized prostate cancer patients with early biochemical recurrence, consistent with previous research. While this work is limited by its sample size, these findings underscore the potential of liquid biopsy as a biomarker and a complementary tool to PSMA PET/CT to assess disease progression during the follow-up of these patients. Declarations Ethics approval: The study methodology conformed to the standard set by the Declaration of Helsinki and was approved by the Clinical Research Ethics Committee of the Hospital Clínic Barcelona (HCB/2022/0542). Consent to participate: All participants provided written informed consent (HCB/2013/8753) before being included in this study. Consent for publication: Written informed consent was obtained from the patient for publication of this study and accompanying images. Availability of data and material: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Competing Interests: The authors have no relevant financial or non-financial interests to disclose. Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution: All authors (GA, MF, JM, LM, MJR, KQ, RP, MIT, FLR, DF, AA, LI, PP) contributed to the study conception and design. PP and LI coordinated and supervised the study. Material preparation, data collection and analysis were performed by GA, MF, PP and LI. The first draft of the manuscript was written by GA and MF and all other authors (JM, LM, MJR, KQ, RP, MIT, FLR, DF, AA, LI, PP) commented on previous versions of the manuscript. All authors (GA, MF, JM, LM, MJR, KQ, RP, MIT, FLR, DF, AA, LI, PP) read and approved the final manuscript. Acknowledgements: Full list of consortium members and their affiliations for Clinic Barcelona Nuclear Medicine (CBNM) Group. Francisco Campos 6 Sebastián Casanueva-Eliceiry 6,7 Amparo Cobo 6,7 Mercè Moragas 6 África Muxí 6,7 Aida Niñerola 6,7,8 Andrés Perissinotti 6,7 Inmaculada Romero 6,7 Xavier Setoain 6,7,8 Sergi Vidal-Sicart 6,7 References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. 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Tables Table 1: Demographic and clinicopathological data of the cohort studied Characteristics Cohort patients studied (n=32) Age of diagnosis, median (range) 63 (45-76) Pathologies of interest, n (%) None DM HT Dyslipidemia 12 (37.5) 3 (9.4) 15 (46.9) 11 (34.4) Initial PSA ng/mL, median (range) 7.8 (2.04-38.4) Prostatic volume cc, median (range) 35 (15-98) ISUP score, n (%) 1 2 3 4 5 3 (9.4) 6 (18.75) 11 (34.4) 6 (18.75) 5 (15.6) Pathological Stage, n (%) a pT2 pT3a pT3b 12 (37.5) 9 (28.1) 9 (28.1) pN, n (%) x 0 1 7 (22) 18 (56.25) 6 (18.75) Number of previous recurrences, n (%) 0 1 2 20 (60) 10 (33.3) 2 (6.6) Abbreviations: PCa, prostate cancer; DM, diabetes mellitus; HT, hypertension; PSA, prostate-specific antigen; ISUP, International Society for Urological Pathology. a The pathological stage of one patient was not available from medical records. Table 2. Patients classified according to recurrence sites with their corresponding staging Recurrence site Staging n n total No recurrence T0N0M0 12 12 Local TrN0M0 4 4 Pelvic nodal Only nodal T0N1M0 6 7 Local + nodal TrN2M0 1 Metastatic Distant nodes only T0N0M1a 1 9 Bone metastasis only T0N0M1b 2 Local + Distant nodes TrN0M1a 1 Pelvic nodes + Distant nodes T0N1M1a 1 Pelvic nodes + Bone metastasis T0N1M1b 1 Pelvic nodes (1) + Distant nodes + Bone metastasis T0N1M1b 1 Pelvic nodes (>1) + Distant nodes + Bone metastasis T0N2M1b 2 Table 3. PSA, wbPSMA-TV, TL-PSMA40, cfDNA concentration and mean cfDNA fragment size fraction for extension of disease; median (IQR). Extension of disease PSA (ng/mL) wbPSMA-TV40 (cc) wbTL-PSMA40 (cc) wbSUVmax wbSUVmean cfDNA concentration (ng/mL) Mean cfDNA fragmentation Total cohort (n=32) 0.74 (0.94) 0.45 (2.12) 1.70 (8.47) 3.77 (8.19) 2.25 (5.00) 11.03 (7.46) 160 (30.25) No measurable disease (T0N0M0) (n=12) 0.33 (0.7) 0 0 0 0 11.76 (8.27) 175.5 (27.5) Local recurrence (Tr) (n=4) 0.58 (3.92) 0.65 (0.85) 3.52 (4.35) 5.73 (9.96) 3.35 (3.39) 11.53 (1.9) 150.5 (26.75) Pelvic nodal disease (N1, N2) (n=7) 0.79 (0.80) 1.37 (2.22) 3.58 (5.79) 4.31 (5.87) 2.61 (3.88) 10.3 (7.24) 149 (40) Distant nodal disease (M1a) (n=3) 1.39 (2.78) 1.74 (0.82) 11.60 (16.09) 16.7 (21.95) 10.48 (14.28) 9.75 (4) 184 (17.5) Bone metastasis (M1b) (n=6) 1.6 (6.82) 4.43 (4.27) 10.92 (27.38) 5.91 (18.08) 3.55 (11.72) 7.35 (5.9) 161.5 (37) Cite Share Download PDF Status: Published Journal Publication published 18 Dec, 2024 Read the published version in EJNMMI Research → Version 1 posted Editorial decision: Minor Revision 04 Oct, 2024 Reviewers agreed at journal 04 Sep, 2024 Reviewers invited by journal 01 Sep, 2024 Editor assigned by journal 30 Aug, 2024 First submitted to journal 28 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4905783","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":347987357,"identity":"75224b93-fb4f-4b72-affe-c44ec477da91","order_by":0,"name":"Gary Amseian","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYDADNgYGxsdgFjNzA9FamI0ZGAyAFCORWkC6pMFaGAhokXc/+0ziZ06dHB/72WPVBRV/ovnbgVp+VGzDqcXwTLqZZO+2w8ZsPHlpt2ecMcidcZixgbHnzG3cWhrS2CR4tx1IbGPIMbvN22aQ2wDUwszYhkdL/zM2yb/b6urb+N+YFYO0zCekRV4ijU2adxtzAptEjhkzSMsGQloMJJ4xW8tuO2zYJvHGWJrnjHHuRqCWg/j8It+fxnjz7bY6efn+HMPPPBVyufPOHz744EcFHlsOMLBIYIgewKkeZEsDA/MHfApGwSgYBaNgFDAAAMl9Ut9/UuUSAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0005-5464-1342","institution":"Hospital Clinic de Barcelona","correspondingAuthor":true,"prefix":"","firstName":"Gary","middleName":"","lastName":"Amseian","suffix":""},{"id":347987358,"identity":"bb79cf3f-a357-4ce8-9651-19ace28a4491","order_by":1,"name":"Marcel Figueras","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Marcel","middleName":"","lastName":"Figueras","suffix":""},{"id":347987359,"identity":"469e4a2a-1566-41c4-8ca4-5c3c0b00202a","order_by":2,"name":"Joel Mases","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Joel","middleName":"","lastName":"Mases","suffix":""},{"id":347987360,"identity":"984e1e3d-8d08-489b-b705-18cd4cde855c","order_by":3,"name":"Lourdes Mengual","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Lourdes","middleName":"","lastName":"Mengual","suffix":""},{"id":347987361,"identity":"a8c87201-d188-40a2-9a4e-dfa7ea6825f7","order_by":4,"name":"Maria-Jose Ribal","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Maria-Jose","middleName":"","lastName":"Ribal","suffix":""},{"id":347987362,"identity":"81a1e771-6fc5-4d87-b1a1-d41869caa5ac","order_by":5,"name":"Katherine Quintero","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Katherine","middleName":"","lastName":"Quintero","suffix":""},{"id":347987363,"identity":"c2a3a4b1-3e4a-4605-8b2d-583d8c3f921d","order_by":6,"name":"Rita Pages","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Rita","middleName":"","lastName":"Pages","suffix":""},{"id":347987364,"identity":"2fd16b8b-dcc2-45bb-8836-93d51604e91a","order_by":7,"name":"Mercedes Ingelmo-Torres","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Mercedes","middleName":"","lastName":"Ingelmo-Torres","suffix":""},{"id":347987365,"identity":"8c1572c8-4be1-4f8c-8764-bb7f2c21c02b","order_by":8,"name":"Fiorella-Lizzeth Roldan","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Fiorella-Lizzeth","middleName":"","lastName":"Roldan","suffix":""},{"id":347987366,"identity":"1a104ccb-50b6-496a-8d1f-4739b890d7a2","order_by":9,"name":"David Fuster","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Fuster","suffix":""},{"id":347987367,"identity":"45cf1805-2e25-4c4f-a690-c2a29b46c4c9","order_by":10,"name":"Antonio Alcaraz","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Alcaraz","suffix":""},{"id":347987368,"identity":"3ca54f38-4c6f-41dd-affd-740410247b62","order_by":11,"name":"Laura Izquierdo","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Izquierdo","suffix":""},{"id":347987369,"identity":"f6256b3d-e986-453d-938a-fa0b29b24d2a","order_by":12,"name":"Pilar Paredes","email":"","orcid":"https://orcid.org/0000-0002-8097-9217","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Pilar","middleName":"","lastName":"Paredes","suffix":""},{"id":347987370,"identity":"dfdfb686-22c7-4f2a-94ed-424fe3f1f7f5","order_by":13,"name":"CBNM Group Clinic Barcelona Nuclear Medicine","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"CBNM","middleName":"Group Clinic Barcelona Nuclear","lastName":"Medicine","suffix":""}],"badges":[],"createdAt":"2024-08-13 09:16:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4905783/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4905783/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13550-024-01170-x","type":"published","date":"2024-12-18T15:56:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66959332,"identity":"4f948fd0-9ff0-4c50-87e3-56aaf0882908","added_by":"auto","created_at":"2024-10-18 12:13:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":857859,"visible":true,"origin":"","legend":"\u003cp\u003ePSMA PET/CT showing metastatic sites of biochemical recurrence\u003c/p\u003e\n\u003cp\u003ePSMA PET/CT performed with [\u003csup\u003e18\u003c/sup\u003eF]F-DCFPyL in a 68 year-old patient with biochemical recurrence. Fused PET/CT axial images (a,b,c) and MIP image (d) revealed a pelvic right external iliac node (thick arrow), a distant lymph node at the prepubic area (thin arrow), and a bone metastasis in a right rib (arrowhead), corresponding to a T0N1M1b stage according to PROMISE v2 criteria. The patient presented with a wbMTV40 of 6.37 cc and a wbTLG40 of 149.95. The cfDNA level was 4.42ng/mL with a mean fragment size of 133bp. The patient had a renal graft in the right iliac fossa.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4905783/v1/9e9c597584e20be4e5a77585.png"},{"id":66959548,"identity":"bd2f92b9-370d-41a3-93a2-cf50762fc623","added_by":"auto","created_at":"2024-10-18 12:21:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":169193,"visible":true,"origin":"","legend":"\u003cp\u003ePSA level correlates with molecular imaging data, including wbPSMA-TV40 (a), wbTL-PSMA40 (b), wbSUVmean (c) and wbSUVmax (d).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4905783/v1/9ae3378cee4405b96cd6f7af.png"},{"id":66959330,"identity":"ecb67256-8989-45bf-b26d-53b314e6a3fe","added_by":"auto","created_at":"2024-10-18 12:13:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":102829,"visible":true,"origin":"","legend":"\u003cp\u003eMean cfDNA fragment size fraction correlates with tumour burden measured with wbPSMA-TV.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4905783/v1/0a974626951ca39459cd6ac7.png"},{"id":72201373,"identity":"10104c68-2982-4a65-a361-1d5545f66de0","added_by":"auto","created_at":"2024-12-23 16:00:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2056342,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4905783/v1/2471be1d-3e48-46c8-8e39-8d497229f3cd.pdf"}],"financialInterests":"","formattedTitle":"cfDNA Fragmentation Patterns Correlates with Tumor Burden Measured via PSMA PET/CT Volumetric Parameters in Patients with Biochemical Recurrence of Prostate Cancer","fulltext":[{"header":"Introduction","content":"\u003cp\u003eProstate cancer (PCa) is the second most common cancer in men worldwide and the most frequent malignancy in Europe and the USA. It had an estimated global mortality of 375,000 in 2020 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Serum prostate-specific antigen (PSA) quantification, imaging techniques such as magnetic resonance imaging (MRI), and prostate biopsy are the current tools for PCa diagnosis (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Usually, treatment of localized PCa patients includes a local approach like radical prostatectomy (RP) or radiotherapy (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). After treatment, serial PSA quantification is used to detect biochemical recurrence (BR). Overall, within two years of RP, approximately 14% of overall PCa patients experience BR (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and this percentage is higher in patients with high-risk factors (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Despite BR being detected, not all patients present detectable disease recurrence with current imaging techniques such as computed tomography (CT) and bone scintigraphy.\u003c/p\u003e \u003cp\u003eProstate-specific membrane antigen (PSMA) is highly expressed in PCa cells,(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) making it an excellent target for diagnostic imaging. PSMA PET has demonstrated superior diagnostic accuracy and a greater impact on management decisions(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) compared with conventional methods. Particularly during the early stages of BR, both anatomical imaging and bone scintigraphy frequently fail to accurately identify the site of relapse, while PSMA PET has proven useful in detecting recurrent lesions, even in patients with low PSA levels (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). PSMA PET can pinpoint the exact location of recurrence, enabling localized treatments such as targeted radiotherapy or salvage surgery (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Thus, PSMA PET has emerged as the preferred imaging tool for diagnosis in the setting of BR after radiotherapy treatment(\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and is recommended after RP, as indicated in the EAU guidelines (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), especially at low PSA levels (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Assessing tumour volume (denoted as PSMA-TV) is advised during PSMA PET interpretation, as growing evidence suggests that it may be a prognostic factor of overall survival (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAlternatively, liquid biopsy techniques to study molecular biomarkers in several cancer types, including PCa are gaining considerable importance. Liquid biopsy analysis provides cancer-specific information from a simple and minimally invasive blood extraction that can be repeatedly obtained from patients, making it an ideal approach for disease monitoring, during both diagnosis and follow-up (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). One of the components found in liquid biopsy samples is cell-free DNA (cfDNA), which consists of highly fragmented nucleic acids secreted from apoptotic cells, both healthy and cancer cells. High cfDNA levels are associated with poor prognosis in different urologic tumours, including PCa (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). It seems that cfDNA secreted by tumour cells is shorter than that originating from non-malignant cells (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Moreover, cfDNA fragmentation patterns can provide diagnostic and prognostic value.\u003c/p\u003e\u003cp\u003eThere is scarce evidence about the association between liquid biopsy and PSMA PET/CT findings (\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), however, there are promising results. To the best of our knowledge, the correlation between PSMA PET and liquid biopsy in early recurring PCa patients has not been studied yet. Therefore, this study aimed to assess the correlation between cfDNA concentration, and mean cfDNA fragment fraction and tumour burden assessed by PSMA PET in the setting of BR PCa patients.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003ePatients\u003c/p\u003e \u003cp\u003ePatients referred to the Nuclear Medicine department for PSMA PET/CT in the setting of BR of PCa between February 2022 and February 2023 were prospectively included in the study. None of the patients included had other active neoplasms. All patients had previously undergone RP. BR was defined as PSA\u0026thinsp;\u0026gt;\u0026thinsp;0.4 ng/ml and rising as per EAU guidelines (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). As a PSMA PET/CT performance criterion is PSA\u0026thinsp;\u0026gt;\u0026thinsp;0.2 ng/ml, we also included 10 patients with PSA levels ranging from 0.2 to 0.4 ng/ml. The clinical and pathological characteristics of these patients are shown in Table\u0026nbsp;1. All BR patients were re-staged with PSMA PET/CT scans using [\u003csup\u003e18\u003c/sup\u003eF]F-DCFPyL in 29 patients (91%) or [\u003csup\u003e68\u003c/sup\u003eGa]Ga-PMSA-11 in three (9%). The median PSA level during recurrence was 0.74 ng/mL (IQR 0.94).\u003c/p\u003e \u003cp\u003eOne 10 mL EDTA tube of peripheral blood was collected when PET PSMA was performed due to BR and stored at 4⁰C until processed within the following four hours. Peripheral blood was then used to isolate cfDNA.\u003c/p\u003e \u003cp\u003ePSMA PET/CT acquisition protocol\u003c/p\u003e \u003cp\u003ePSMA PET/CT was performed using a Biograph mCT TrueV PET/CT hybrid device (Siemens, Germany), with low-dose CT for attenuation correction and image fusion. The radiotracers used were [\u003csup\u003e18\u003c/sup\u003eF]F-DCFPyL and [\u003csup\u003e68\u003c/sup\u003eGa]Ga-PSMA-11, at doses of 4 and 2 MBq/Kg, respectively. PSMA PET/CT imaging was acquired from the skull base to the proximal third of the thigh with arms raised above the head, 60 min after radiotracer injection for [\u003csup\u003e68\u003c/sup\u003eGa]Ga-PSMA-11 and 90 minutes p.i. for fluorine tracer, and at 2.5 min per bed. PET data reconstruction was performed using a standard iterative algorithm from CT records.\u003c/p\u003e \u003cp\u003eImage analysis and interpretation\u003c/p\u003e \u003cp\u003ePSMA PET/CT images were assessed using a workstation (syngo.PET\u0026amp;CT Oncology VA20A, Siemens Healthineers AG, Germany) by a physician in training and a senior nuclear medicine specialist experienced in PSMA PET/CT. Any discrepancies were resolved by consensus. Pathological findings were defined following the Second Version of the Prostate Cancer Molecular Imaging Standardized Evaluation Framework Including Response Evaluation for Clinical Trials (PROMISEv2) criteria (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Spherical or ellipsoidal regions of interest were placed over all pathological uptakes on PSMA PET/CT images, ensuring that the entire lesion was enclosed in axial, sagittal, and coronal projections. Standarized uptake values (SUVs) (SUVmax and SUVmean) were automatically calculated based on measured activity concentration (Bq/mL) multiplied by patient weight (kg) and normalized to injected activity (Bq).\u003c/p\u003e \u003cp\u003eTo obtain PSMA-derived tumour volume values (PSMA-TV), the contouring margins of each lesion were delineated by a threshold of 40% SUVmax using an SUV-based automated contouring program (Syngo.via, Siemens Healthineers, Germany). Volumetric whole-body analysis was performed to assess the PSMA tumour burden, including all lesions: local recurrence, lymph nodes, and distant metastases, which together constitute the whole-body PSMA tumour burden. The sum of the PSMA-TV of each lesion was defined as whole-body (wb) PSMA-TV (wbPSMA-TV), which was recorded and calculated for the entire disease.\u003c/p\u003e \u003cp\u003eTo report the extent and location of recurrence lesions in PSMA PET images, PROMISEv2 criteria were used. Patients were classified into subgroups based on the presence of local, nodal, and/or metastatic disease according to a combination of the following categories: no local tumour (T0), local recurrence (Tr), with no positive pelvic lymph nodes (N0), lymph node metastases in a single pelvic lymph node region (N1), lymph node metastases in more than one pelvic lymph node region (N2), no distant metastases (M0), lesions in distant lymph node regions (M1a), bone metastases (M1b), and metastases in other sites (M1c).\u003c/p\u003e \u003cp\u003ecfDNA isolation and quantification\u003c/p\u003e \u003cp\u003eTo separate plasma, blood samples were centrifuged at 3500 rpm for 15 min at 4⁰C, followed by plasma centrifugation at 16000 x g for 10 min at 4⁰C to remove any remaining cells. Plasma samples were then stored at -80⁰C until cfDNA extraction.\u003c/p\u003e \u003cp\u003ecfDNA was extracted from 1.5 to 4 mL of plasma (depending on availability) using the QIAamp Circulating Nucleic Acid Kit (Qiagen, Hilden, Germany), according to the manufacturer\u0026rsquo;s instructions. Plasma cfDNA concentration was obtained using the Quant-it PicoGreen dsDNA Assay kit. The mean cfDNA fragment size fraction was evaluated using the Agilent 2200 TapeStation System. The average size fraction from short fragments (100\u0026ndash;250 bp) was calculated from the electropherogram.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003ePSMA PET/CT data were compared against cfDNA levels and mean fragmentation patterns in the cohort studied using Spearman\u0026rsquo;s rank correlation coefficient or χ\u0026sup2; test depending on the variable\u0026rsquo;s nature. Moreover, PSMA PET/CT and liquid biopsy data were correlated with clinicopathological variables from each patient including PSA levels at diagnosis and at the time of BR, ISUP (International Society for Urological Pathology) score, pathological stage, affected margins, regional lymph node metastasis, among others, using Spearman\u0026rsquo;s rank correlation coefficient or χ\u0026sup2; test depending on the variable\u0026rsquo;s nature. Statistical significance was established at a p-value of 0.05. All analyses were carried out with the SPSS software package (IMB SPSS Statistics 25).\u003c/p\u003e \u003cp\u003e All participants provided written informed consent (HCB/2013/8753) before being included in this study. The study methodology conformed to the standard set by the Declaration of Helsinki and was approved by the Clinical Research Ethics Committee of the Hospital Cl\u0026iacute;nic Barcelona (HCB/2022/0542).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 32 patients with BR included, 12 (37.5%) had no PSMA PET/CT-measurable disease. Four patients (12.5%) presented local recurrence and seven (21.9%) had a recurrence in the pelvic lymph nodes, one of whom also had local recurrence. Nine patients (28.1%) presented metastatic recurrence, with or without local or nodal recurrence (Figure 1). The recurrence sites with their corresponding staging according to PROMISEv2 criteria are detailed in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePSA levels correlated with molecular imaging data, including wbPSMA-TV40 (Spearman’s correlation coefficient (SCC)=.489; p=0.005), wbTL-PSMA40 (SCC=.449; p=0.01), wbSUVmean (SCC=.418; p=0.017) and wbSUVmax (SCC=.428; p=0.014) (Fig. 2).\u003c/p\u003e\n\u003cp\u003ePSMA PET/CT parameters—such as wbPSMA-TV, wbTL-PSMA40, wbTL-PSMA40, wbSUVmax and wbSUVmean—\u0026nbsp;and liquid biopsy parameters—such as cfDNA concentration and mean cfDNA fragmentation patterns—in recurrent patients based on disease extension are shown in Table 3.\u003c/p\u003e\n\u003cp\u003eThe mean cfDNA fragment size fraction was inversely correlated with tumour burden measured via wbPSMA-TV, with an SCC of -0.451 and a p-value of 0.009 (Figure 3). No correlation was found between cfDNA concentration and PSMA PET/CT data.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAfter local treatment, between 25% and 50% of PCa patients will develop BR and be at an increased risk of developing metastasis. Imaging can help to determine whether the recurrence is local or distant; however, its performance is PSA-dependent. Liquid biopsy may be useful in combination with PSMA PET to improve metastasis assessment.\u003c/p\u003e \u003cp\u003eWe assessed the correlation between cfDNA concentration and mean cfDNA fragment size fraction and image-derived volumetric parameters from PSMA PET/CT in a cohort of PCa patients with RP at the time of BR. To our knowledge, this is the first study focused on PSMA PET and liquid biopsy in early recurring PCa patients. We found a statistically significant negative correlation between wbPSMA-TV and mean cfDNA fragment size fraction. Short cfDNA fragments are associated with apoptosis of cancerous cells, implying that these patients might have a higher tumour burden and a higher risk of progression to metastatic disease. This result is consistent with other studies conducted to date in different settings (\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Chen et al. compared cfDNA in healthy controls (n\u0026thinsp;=\u0026thinsp;34), patients with localized PCa (n\u0026thinsp;=\u0026thinsp;112), and patients with metastatic castration-resistant prostate cancer (mCRPC) (n\u0026thinsp;=\u0026thinsp;122). They found that localized PCa patients had a shorter average cfDNA fragment size when compared with controls (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Similar correlations have been observed in other malignancies. In a previous study on stage III-IV non-small cell lung cancer (NSCLC) patients (n\u0026thinsp;=\u0026thinsp;53) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e); cfDNA fragmentation correlated with fludeoxyglucose-18 (FDG) PET/CT parameters from primary tumour, extrapulmonary disease and whole-body disease. In this sense, mean cfDNA fragmentation patterns in combination with PSMA PET parameters might be useful to detect patients with a high risk of progression.\u003c/p\u003e \u003cp\u003eOn the other hand, we found no correlation between cfDNA levels and volumetric parameters from PSMA PET/CT. In addition, there were no differences in cfDNA levels between patients with different recurrence sites classified using PSMA PET. Kluge et al. compared the correlation of liquid biopsy data and PSMA PET between patients with hormone-sensitive prostate cancer (HSPC) (n\u0026thinsp;=\u0026thinsp;74) and mCRPC (n\u0026thinsp;=\u0026thinsp;74). They found that cfDNA levels were weakly correlated with PSMA-TV in the mCRPC group but not in the HSPC group (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Chen et al. observed that plasma cfDNA concentrations were significantly elevated in patients with mCRPC but not in patients with localized disease. Along that same line, a study from Gonz\u0026aacute;lez de Aledo-Castillo et al. on NSCLC found a positive correlation between cfDNA concentration and extrapulmonary FDG PET/CT volumetric parameters, while no association was found between cfDNA concentration and FDG PET/CT parameters from local disease. The previously published results indicated a stronger correlation in advanced disease, which account for the absence of correlation in our series.\u003c/p\u003e \u003cp\u003eIt is important to note that, as illustrated in the cohort studied in this work, BR is a highly heterogeneous entity that includes patients with local, nodal or oligometastatic extension. Our cohort included patients with early BR, with low tumour burden. Regarding liquid biopsy and PSMA PET parameters, this group of patients might behave similarly to those with localized disease in previously described studies\u0026mdash;which also found no significant differences in cfDNA concentration. Furthermore, it could differ from cohorts with more advanced stages of the disease, specifically in patients with mCRPC, in whom higher levels of cfDNA were found. Considering this, cfDNA concentration may identify patients with high tumour burden but it might present limitations when distinguishing between healthy individuals and patients with localized PCa or early BR.\u003c/p\u003e \u003cp\u003ePSMA PET/CT may produce false negatives in patients with micrometastases and oligometastases. Studies by Budaus et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) and Van Leeuwen et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) comparing presurgical PSMA PET/CT with histopathological findings of removed lymph nodes reported a 33% and 64% sensitivity for lymph node metastasis detection, respectively. Both studies found that false-negative lesions were significantly lower than true-positives. This shows that lesion size impacts PSMA PET detection, which is a crucial matter in early recurrence with a small tumour burden. This could have altered the correlation between PSMA PET/CT and liquid biopsy parameters, especially considering that cfDNA is a non-tumour-specific marker that, despite its utility and availability, can be affected by other factors, such as tissue damage or chronic diseases. Despite this, we found a statistically significant correlation between liquid biopsy and PSMA PET/CT, consistent with previous studies on the subject.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first work to focus specifically on patients with BR. We acknowledge the limitations of our study, mainly the limited sample size that might have affected the statistical analysis, thus hindering the conclusions. However, given the difficulty of detecting disease in patients with early BR of PCa, we believe cfDNA fragmentation could serve as a biomarker to identify oligometastatic patients with low disease burden during follow-up. Further research with larger cohorts is warranted to validate these results and explore the clinical utility of cfDNA fragmentation analysis in this context.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis prospective study demonstrated a statistically significant negative correlation between cfDNA fragmentation patterns and PSMA PET/CT volumetric parameters in localized prostate cancer patients with early biochemical recurrence, consistent with previous research. While this work is limited by its sample size, these findings underscore the potential of liquid biopsy as a biomarker and a complementary tool to PSMA PET/CT to assess disease progression during the follow-up of these patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e The study methodology conformed to the standard set by the Declaration of Helsinki and was approved by the Clinical Research Ethics Committee of the Hospital Clínic Barcelona (HCB/2022/0542).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e All participants provided written informed consent (HCB/2013/8753) before being included in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from the patient for publication of this study and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u0026nbsp;\u003c/strong\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;The authors have no relevant financial or non-financial interests to disclose.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution:\u003c/strong\u003e All authors (GA, MF, JM, LM, MJR, KQ, RP, MIT, FLR, DF, AA, LI, PP)\u0026nbsp;contributed to the study conception and design. PP and LI coordinated and supervised the study. Material preparation, data collection and analysis were performed by GA, MF, PP and LI. The first draft of the manuscript was written by GA and MF and all other authors (JM, LM, MJR, KQ, RP, MIT, FLR, DF, AA, LI, PP)\u0026nbsp;commented on previous versions of the manuscript. All authors (GA, MF, JM, LM, MJR, KQ, RP, MIT, FLR, DF, AA, LI, PP)\u0026nbsp;read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFull list of consortium members and their affiliations for Clinic Barcelona Nuclear Medicine (CBNM) Group.\u003c/p\u003e\n\u003cp\u003eFrancisco Campos \u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSebastián Casanueva-Eliceiry \u003csup\u003e6,7\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAmparo Cobo \u003csup\u003e6,7\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eMercè Moragas \u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eÁfrica Muxí \u003csup\u003e6,7\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAida Niñerola \u003csup\u003e6,7,8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAndrés Perissinotti \u003csup\u003e6,7\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eInmaculada Romero \u003csup\u003e6,7\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eXavier Setoain \u003csup\u003e6,7,8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSergi Vidal-Sicart \u003csup\u003e6,7\u003c/sup\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. 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Eur J Nucl Med Mol Imaging [Internet]. 2021;48(11):3631\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://link.springer.com/\u003c/span\u003e\u003cspan address=\"https://link.springer.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00259-021-05306-2\u003c/span\u003e\u003cspan address=\"10.1007/s00259-021-05306-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeifert R, Emmett L, Rowe SP, Herrmann K, Hadaschik B, Calais J et al. Second Version of the Prostate Cancer Molecular Imaging Standardized Evaluation Framework Including Response Evaluation for Clinical Trials (PROMISE V2). Eur Urol [Internet]. 2023;83(5):405\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.eururo.2023.02.002\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2023.02.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKluge K, Einspieler H, Haberl D, Spielvogel C, Stoiber S, Vraka C et al. Examining the Relationship and Prognostic Significance of Cell-Free DNA Levels and the PSMA-Positive Tumor Volume in Men with Prostate Cancer: A Retrospective\u0026ndash;Prospective [ 68 Ga]Ga-PSMA-11 PET/CT Study. Journal of Nuclear Medicine [Internet]. 2024;65(1):63\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://jnm.snmjournals.org/lookup/doi/10.2967/jnumed.123.266158\u003c/span\u003e\u003cspan address=\"http://jnm.snmjournals.lookup/doi/10.2967/jnumed.123.266158\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBud\u0026auml;us L, Leyh-Bannurah SR, Salomon G, Michl U, Heinzer H, Huland H, et al. Initial Experience of 68Ga-PSMA PET/CT Imaging in High-risk Prostate Cancer Patients Prior to Radical Prostatectomy. Eur Urol. 2016;69(3):393\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Leeuwen PJ, Emmett L, Ho B, Delprado W, Ting F, Nguyen Q, et al. Prospective evaluation of 68Gallium-prostate-specific membrane antigen positron emission tomography/computed tomography for preoperative lymph node staging in prostate cancer. BJU Int. 2017;119(2):209\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Demographic and clinicopathological data of the cohort studied\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCohort patients studied (n=32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge of diagnosis, median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e63 (45-76)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePathologies of interest, n (%)\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eDM\u003c/p\u003e\n \u003cp\u003eHT\u003c/p\u003e\n \u003cp\u003eDyslipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (37.5)\u003c/p\u003e\n \u003cp\u003e3 (9.4)\u003c/p\u003e\n \u003cp\u003e15 (46.9)\u003c/p\u003e\n \u003cp\u003e11 (34.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInitial PSA ng/mL, median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.8 (2.04-38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProstatic volume cc, median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35 (15-98)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eISUP score, n (%)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (9.4)\u003c/p\u003e\n \u003cp\u003e6 (18.75)\u003c/p\u003e\n \u003cp\u003e11 (34.4)\u003c/p\u003e\n \u003cp\u003e6 (18.75)\u003c/p\u003e\n \u003cp\u003e5 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePathological Stage, n (%)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003epT2\u003c/p\u003e\n \u003cp\u003epT3a\u003c/p\u003e\n \u003cp\u003epT3b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (37.5)\u003c/p\u003e\n \u003cp\u003e9 (28.1)\u003c/p\u003e\n \u003cp\u003e9 (28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003epN, n (%)\u003c/p\u003e\n \u003cp\u003ex\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (22)\u003c/p\u003e\n \u003cp\u003e18 (56.25)\u003c/p\u003e\n \u003cp\u003e6 (18.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of previous recurrences, n (%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 (60)\u003c/p\u003e\n \u003cp\u003e10 (33.3)\u003c/p\u003e\n \u003cp\u003e2 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: PCa, prostate cancer; DM, diabetes mellitus; HT, hypertension; PSA, prostate-specific antigen; ISUP, International Society for Urological Pathology.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e The pathological stage of one patient was not available from medical records. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Patients classified according to recurrence sites with their corresponding staging\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"540\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eRecurrence site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eStaging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003en total\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eNo recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eT0N0M0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eLocal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eTrN0M0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003ePelvic nodal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOnly nodal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eT0N1M0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLocal + nodal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eTrN2M0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003eMetastatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eDistant nodes only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eT0N0M1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eBone metastasis only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eT0N0M1b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eLocal + Distant nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eTrN0M1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003ePelvic nodes + Distant nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eT0N1M1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePelvic nodes + Bone metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eT0N1M1b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePelvic nodes (1) + Distant nodes + Bone metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eT0N1M1b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePelvic nodes (\u0026gt;1) + Distant nodes + Bone metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eT0N2M1b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e PSA, wbPSMA-TV, TL-PSMA40, cfDNA concentration and mean cfDNA fragment size fraction for extension of disease; median (IQR).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"598\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8763%;\"\u003e\n \u003cp\u003eExtension of disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.36455%;\"\u003e\n \u003cp\u003ePSA\u003cbr\u003e\u0026nbsp;(ng/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3712%;\"\u003e\n \u003cp\u003ewbPSMA-TV40 (cc)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3679%;\"\u003e\n \u003cp\u003ewbTL-PSMA40 (cc)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8763%;\"\u003e\n \u003cp\u003ewbSUVmax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0468%;\"\u003e\n \u003cp\u003ewbSUVmean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3813%;\"\u003e\n \u003cp\u003ecfDNA concentration\u003cbr\u003e\u0026nbsp;(ng/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.7157%;\"\u003e\n \u003cp\u003eMean cfDNA fragmentation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8763%;\"\u003e\n \u003cp\u003eTotal cohort (n=32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36455%;\"\u003e\n \u003cp\u003e0.74 (0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.3712%;\"\u003e\n \u003cp\u003e0.45 (2.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3679%;\"\u003e\n \u003cp\u003e1.70 (8.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.8763%;\"\u003e\n \u003cp\u003e3.77 (8.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.0468%;\"\u003e\n \u003cp\u003e2.25 (5.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.3813%;\"\u003e\n \u003cp\u003e11.03 (7.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.7157%;\"\u003e\n \u003cp\u003e160 (30.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8763%;\"\u003e\n \u003cp\u003eNo measurable disease (T0N0M0) (n=12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36455%;\"\u003e\n \u003cp\u003e0.33 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.3712%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3679%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.8763%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.0468%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.3813%;\"\u003e\n \u003cp\u003e11.76 (8.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.7157%;\"\u003e\n \u003cp\u003e175.5 (27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8763%;\"\u003e\n \u003cp\u003eLocal recurrence (Tr) (n=4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36455%;\"\u003e\n \u003cp\u003e0.58 (3.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.3712%;\"\u003e\n \u003cp\u003e0.65 (0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3679%;\"\u003e\n \u003cp\u003e3.52 (4.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.8763%;\"\u003e\n \u003cp\u003e5.73 (9.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.0468%;\"\u003e\n \u003cp\u003e3.35 (3.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.3813%;\"\u003e\n \u003cp\u003e11.53 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.7157%;\"\u003e\n \u003cp\u003e150.5 (26.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8763%;\"\u003e\n \u003cp\u003ePelvic nodal disease (N1, N2) (n=7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36455%;\"\u003e\n \u003cp\u003e0.79 (0.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.3712%;\"\u003e\n \u003cp\u003e1.37 (2.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3679%;\"\u003e\n \u003cp\u003e3.58 (5.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.8763%;\"\u003e\n \u003cp\u003e4.31 (5.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.0468%;\"\u003e\n \u003cp\u003e2.61 (3.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.3813%;\"\u003e\n \u003cp\u003e10.3 (7.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.7157%;\"\u003e\n \u003cp\u003e149 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8763%;\"\u003e\n \u003cp\u003eDistant nodal disease (M1a) (n=3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36455%;\"\u003e\n \u003cp\u003e1.39 (2.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.3712%;\"\u003e\n \u003cp\u003e1.74 (0.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3679%;\"\u003e\n \u003cp\u003e11.60 (16.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.8763%;\"\u003e\n \u003cp\u003e16.7 (21.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.0468%;\"\u003e\n \u003cp\u003e10.48 (14.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.3813%;\"\u003e\n \u003cp\u003e9.75 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.7157%;\"\u003e\n \u003cp\u003e184 (17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8763%;\"\u003e\n \u003cp\u003eBone metastasis (M1b) (n=6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36455%;\"\u003e\n \u003cp\u003e1.6 (6.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.3712%;\"\u003e\n \u003cp\u003e4.43 (4.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3679%;\"\u003e\n \u003cp\u003e10.92 (27.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.8763%;\"\u003e\n \u003cp\u003e5.91 (18.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.0468%;\"\u003e\n \u003cp\u003e3.55 (11.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.3813%;\"\u003e\n \u003cp\u003e7.35 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.7157%;\"\u003e\n \u003cp\u003e161.5 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"ejnmmi-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejre","sideBox":"Learn more about [EJNMMI Research](http://ejnmmires.springeropen.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ejre/default.aspx","title":"EJNMMI Research","twitterHandle":"@officialEANM","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"prostate cancer, biochemical recurrence, PSMA PET, liquid biopsy","lastPublishedDoi":"10.21203/rs.3.rs-4905783/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4905783/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eProstate cancer recurrence following primary treatment poses a significant clinical challenge, particularly when detected through biochemical recurrence at low PSA levels. Conventional imaging modalities often fail to localize the disease at this early stage. PSMA PET has demonstrated superior sensitivity in detecting recurrent lesions, even in patients with low PSA. Concurrently, liquid biopsy, through analysis of cell-free DNA (cfDNA), offers a minimally invasive approach for monitoring disease. There is scarce evidence about the association between liquid biopsy and PSMA PET/CT findings. This study aimed to assess the correlation between liquid biopsy and tumor burden assessed by PSMA PET/CT in early recurring prostate cancer patients.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePSMA PET/CT and liquid biopsies of 32 patients in biochemical recurrence were analyzed. 12 patients (37.5%) had no PSMA PET-measurable disease. Four patients (12.5%) presented local recurrence, seven (21.9%) had recurrence in pelvic lymph nodes, one of whom also had local recurrence. Nine patients (28.1%) presented metastatic recurrence, with or without local or nodal recurrence. PSA levels correlated with molecular imaging data (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), including wbPSMA-TV40, wbTL-PSMA40, wbSUVmean and wbSUVmax. The mean cfDNA fragment size fraction was inversely correlated with tumour burden measured with wbPSMA-TV, with a Spearman correlation coefficient of -0.451 and a p-value of 0.009. No correlation was found between cfDNA concentration and PET-PSMA data.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis prospective study demonstrated a statistically significant negative correlation between cfDNA fragmentation patterns and PSMA PET/CT volumetric parameters in localized prostate cancer patients with early biochemical recurrence. These findings underscore the potential of liquid biopsy as a biomarker and a complementary tool to PSMA PET/CT to assess disease progression during the follow-up of these patients.\u003c/p\u003e","manuscriptTitle":"cfDNA Fragmentation Patterns Correlates with Tumor Burden Measured via PSMA PET/CT Volumetric Parameters in Patients with Biochemical Recurrence of Prostate Cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-18 12:13:05","doi":"10.21203/rs.3.rs-4905783/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor Revision","date":"2024-10-04T05:02:48+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-09-04T10:56:36+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-01T15:40:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-30T23:24:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"EJNMMI Research","date":"2024-08-28T06:19:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"ejnmmi-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejre","sideBox":"Learn more about [EJNMMI Research](http://ejnmmires.springeropen.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ejre/default.aspx","title":"EJNMMI Research","twitterHandle":"@officialEANM","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf346531-205d-4ed6-93c5-08580ef19e02","owner":[],"postedDate":"October 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T15:58:47+00:00","versionOfRecord":{"articleIdentity":"rs-4905783","link":"https://doi.org/10.1186/s13550-024-01170-x","journal":{"identity":"ejnmmi-research","isVorOnly":false,"title":"EJNMMI Research"},"publishedOn":"2024-12-18 15:56:51","publishedOnDateReadable":"December 18th, 2024"},"versionCreatedAt":"2024-10-18 12:13:05","video":"","vorDoi":"10.1186/s13550-024-01170-x","vorDoiUrl":"https://doi.org/10.1186/s13550-024-01170-x","workflowStages":[]},"version":"v1","identity":"rs-4905783","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4905783","identity":"rs-4905783","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}