Optimizing PSMA PET CT: Targeted Imaging Guidelines


Naveen Kella, MD, and Dr. Shadi Esfahani, MD, MPH, delve into patient selection for PSMA PET CT scans, discussing indications spanning initial diagnosis and recurrence, as well as institution guidelines.


Shadi Abdar Esfahani, MD, MPH: Dr Kella, would you please guide us on the type of patients, the group of patients, who would benefit the most from the PSMA PET/CT [scans] and when would you order them?

Naveen Kella, MD: Sure. Currently, PSMA PET/CT testing is indicated for patients who at initial diagnosis…you suspect of having a risk of metastasis. And another indication is for patients who have biochemical recurrence after definitive therapy, such as with radiation or surgery. There is another indication where you’re getting into theranostics, you could also order PSMA PET/CT if you’re considering a patient for lutetium PSMA. With patients…you suspect have metastasis, well, what does that mean exactly? There are guidelines that are coming forth. But typically, patients who are unfavorable to intermediate risk are patients [who] you should be considering for PSMA PET/CT.

For example, if they are Gleason score 4 + 3 on the biopsy or their PSA is over 10 or 50% of their cores are positive, those are all things that go toward unfavorable risk or higher. And those are patients [who] would be appropriate candidates for a PSMA PET/CT testing. The NCCN [National Comprehensive Cancer Network] came out, and other platforms have also come out, with guidelines suggesting that you shouldn’t consider conventional imaging as a prerequisite before ordering a PSMA PET/CT. You can actually order a PSMA PET/CT as frontline imaging for patients, which is really, really important to hear. Hopefully insurance companies will also hear that soon. Right now, that can be a challenge for those of us who are trying to order the test anyway. There [are] guidelines from the AUA [American Urological Association] and others that [discuss] scenario-based situations where you could order a PSMA, which...is really helpful.

For example, one scenario is a patient who has elevated PSA. They have an abnormal digital rectal exam, but you haven’t done the biopsy yet. Is that an appropriate candidate for a PSMA PET/CT? Right now, no, you need to go ahead and do the biopsy. We mentioned if they have unfavorable to intermediate risk [disease] after a biopsy, that’s an appropriate patient. And then if the patient’s disease comes back after definitive therapy, that’s an appropriate patient for a PSMA PET/CT. And then as you go further along the disease process with scenarios, there are situations where you may have a patient who has nonmetastatic disease on conventional imaging, but they’re now castrate resistant. Now, if their PSA is rising and they’re castrate resistant, they’re an appropriate candidate for PSMA PET/CT. And that just makes a lot of intuitive sense because if the PSA is going up, they probably have disease somewhere. Those are the types of patients I would be considering PSMA PET/CT for.

Shadi Abdar Esfahani, MD, MPH: This is very helpful. Thank you very much.

Transcript is AI-generated and edited for clarity and readability.

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