Incorporating Newer Imaging Modalities Into Clinical Practice and Considerations for Nomenclature


Panelists consider how they have incorporated some newer imaging modalities, including PSMA-PET, into their clinical practice, and discuss the terminology that urologists and radiologists have recently used to describe these modalities.


David Albala, MD: Gerry, tell us how you incorporate imaging into your practice—diagnosis, post-treatment monitoring, and how it’s shifted over the years. I watched you gain that tremendous experience doing prostatectomies and now at [Johns] Hopkins [University], 1 of the meccas for prostatectomies. How have the new changes with imaging been incorporated in your practice?

Gerald Andriole, MD: They’re fundamental. For example, I strive to never do a nontargeted, nonimage guided biopsy of the prostate for a man with an abnormal PSA [prostate-specific antigen]. Many times, the MRI will show you an abnormality. If it doesn’t, I revert to micro-ultrasound because it can identify some prostate cancers that aren’t well seen on MRI. The state-of-the-art biopsy of the prostate is an image-guided biopsy.

The random trans fecal biopsy that we knew for the last 4 years isn’t up to the task, so that’s the first thing. The refined imaging from MRI and micro-ultrasound guides my radical prostatectomy if that’s what I’m going to do. I may see or appreciate some subtle extra-prostatic disease on 1 or both of those imaging modalities. That may change my conversation with the man about nerve sparing vs non-nerve sparing. This is a revolution. It has changed everything.

David Albala, MD: I want to back up and look at this from 30,000 feet. This technology has been termed next-generation imaging, new-generation imaging, or targeted precision imaging. I participated in Dave Crawford’s RADAR groups, which looked at this. It was next-generation imaging and new generation, and now it’s KPI [key performance indicator]. How do you incorporate these terms? Do you think we need to get a standard nomenclature? What do you think that is? This isn’t next generation because we’re in that generation. I’ll open it up to all. Gerry, why don’t you take that 1 to start?

Gerald Andriole, MD: Dave, that’s a great point. I’m with you. Calling it next-gen imaging makes it time dependent. As you know, medicine changes all the time. We ought to call it exactly what it is. We’re getting a PET [positron emission tomography] scan using PSMA [prostate-specific membrane antigen], or Axumin, or fluciclovine, or whatever modality you want. There could be other imaging modalities or tracers that will differentiate themselves from what we’re doing. I don’t think we should box ourselves into something like next-gen imaging. It just changed.

David Albala, MD: It was a sexy term. It was sexy 5 years ago because it really was, but now we’re part of that generation and we’re using it on a daily basis.

Ashley Ross, MD, PhD: I agree with Gary. It’s molecular imaging, and that’s probably the best way to think about the category. We’re looking at functions of these cells or characteristics of these cells specific for prostate cancer. If you’re doing FDG [fluorodeoxyglucose] for lung or something like that, it’s for glucose uptake. It’s molecular imaging. If I had to pick 1 of the terms you threw out, right now it’s new-generation imaging. I hate it when people call CT scans conventional imaging. People who are used to rotagrams and stuff like that are like, “What’s this next-gen CT imaging?” I agree with you and with Gerry that we should throw out the terms. It’s PET imaging if you’re doing positron emission. Molecular imaging is a big class. There’s going to be so much evolution and revolutions in modern medicine in a stepwise function over the next decade. It will be impossible to keep up otherwise.

Transcript edited for clarity.

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