Reply to 'Re: Prostate-specific membrane antigen positron emission tomography in addition to multiparametric magnetic resonance imaging and biopsies to select prostate cancer patients for focal therapy’

We agree that prostate-specific membrane antigen–positron emission tomography (PSMA-PET) should be standard of care for staging in higher-risk patients to exclude nodal involvement and distant metastases. Also, the addition of pelvic PSMA-PET to multiparametric MRI (mpMRI) has now been shown to improve sensitivity and negative predictive value (NPV) in the screening setting (PRIMARY trial) [3]. However, our results indicate that PSMA-PET has added value in increasing overall test sensitivity and NPV when used in conjunction with mpMRI and systematic biopsies for local staging. These patients have already been diagnosed with unifocal prostate cancer and need definitive treatment. When focal therapy (FT) is considered, PSMA- PET can exclude extra patients with multifocal disease and guide them to whole-gland treatment. In this setting there is no such thing as ‘excess sensitivity’, and a small reduction in overall test specificity is less relevant, as opposed to a screening scenario where it would pose new diagnostic challenges.