Long-term oncologic outcomes of PSMA PET–guided salvage radiotherapy for biochemical recurrence after radical prostatectomy: A systematic review and meta-analysis.

5121 Background: Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) imaging has demonstrated superior diagnostic accuracy over conventional imaging in localizing recurrent prostate cancer after radical prostatectomy. Previous meta-analyses have established its value in detection and treatment planning; however, whether PSMA-guided salvage radiotherapy (SRT) translates into improved long-term oncologic outcomes remains uncertain. We conducted a systematic review and meta-analysis to assess the impact of PSMA PET-guided SRT on survival outcomes in patients with biochemical recurrence after radical prostatectomy. Methods: A comprehensive search of PubMed, Embase, and Cochrane Library was performed on January 16, 2025. Studies comparing PSMA PET–guided SRT with conventional SRT in post-radical prostatectomy patients with biochemical recurrence were included. Long-term oncologic outcomes including failure-free survival (FFS), biochemical progression-free survival (bPFS) and metastasis-free survival (MFS), were pooled using hazard ratios (HRs). Results: Nine studies comprising 4,278 patients met the inclusion criteria, including 1,418 patients treated with PSMA PET–guided salvage radiotherapy and 2,860 who received conventional salvage radiotherapy. Compared with conventional SRT, PSMA PET–guided SRT was associated with significantly improved FFS (HR, 0.46; 95% CI, 0.28–0.75). However, the PSMA PET-guided SRT group had a significantly higher risk of biochemical progression; bPFS (HR, 1.40; 95% CI, 1.16–1.69) and metastasis; MFS (HR, 3.16; 95% CI, 2.08–4.80). Conclusions: PSMA PET–guided salvage radiotherapy was associated with reduced early treatment failure, as reflected by improved failure-free survival, but a higher risk of biochemical progression and metastatic events. These findings indicate that while PSMA PET-guided intervention may reduce early treatment failure, its impact on long-term disease control remains uncertain and requires further prospective validation.