Whole-body uptake classification and prostate cancer staging in 68 Ga-PSMA-11 PET/CT using dual-tracer learning

Eur J Nucl Med Mol Imaging. 2022 Jan;49(2):517-526. doi: 10.1007/s00259-021-05473-2. Epub 2021 Jul 7.


Purpose: In PSMA-ligand PET/CT imaging, standardized evaluation frameworks and image-derived parameters are increasingly used to support prostate cancer staging. Clinical applicability remains challenging wherever manual measurements of numerous suspected lesions are required. Deep learning methods are promising for automated image analysis, typically requiring extensive expert-annotated image datasets to reach sufficient accuracy. We developed a deep learning method to support image-based staging, investigating the use of training information from two radiotracers.

Methods: In 173 subjects imaged with 68Ga-PSMA-11 PET/CT, divided into development (121) and test (52) sets, we trained and evaluated a convolutional neural network to both classify sites of elevated tracer uptake as nonsuspicious or suspicious for cancer and assign them an anatomical location. We evaluated training strategies to leverage information from a larger dataset of 18F-FDG PET/CT images and expert annotations, including transfer learning and combined training encoding the tracer type as input to the network. We assessed the agreement between the N and M stage assigned based on the network annotations and expert annotations, according to the PROMISE miTNM framework.

Results: In the development set, including 18F-FDG training data improved classification performance in four-fold cross validation. In the test set, compared to expert assessment, training with 18F-FDG data and the development set yielded 80.4% average precision [confidence interval (CI): 71.1-87.8] for identification of suspicious uptake sites, 77% (CI: 70.0-83.4) accuracy for anatomical location classification of suspicious findings, 81% agreement for identification of regional lymph node involvement, and 77% agreement for identification of metastatic stage.

Conclusion: The evaluated algorithm showed good agreement with expert assessment for identification and anatomical location classification of suspicious uptake sites in whole-body 68Ga-PSMA-11 PET/CT. With restricted PSMA-ligand data available, the use of training examples from a different radiotracer improved performance. The investigated methods are promising for enabling efficient assessment of cancer stage and tumor burden.

Keywords: Deep learning; PET/CT; PSMA; Prostate cancer; Staging; miTNM.

MeSH terms

  • Edetic Acid
  • Gallium Isotopes
  • Gallium Radioisotopes
  • Humans
  • Male
  • Positron Emission Tomography Computed Tomography* / methods
  • Prostatic Neoplasms* / diagnostic imaging
  • Prostatic Neoplasms* / pathology


  • Gallium Isotopes
  • Gallium Radioisotopes
  • gallium 68 PSMA-11
  • Edetic Acid