Practice Updates in Prostate Cancer Imaging - Episode 13

Patient Profile 3: High-Risk Prostate Cancer

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Steven Finkelstein, MD, DABR, FACRO, presents a high-risk prostate cancer patient profile for a 74-year-old man with a history of chronic prostatitis.

Neal Shore, MD, FACS: Let’s stick with the theme of high-risk prostate cancer. And Steven, this is your case.

Steven Finkelstein, MD, DABR, FACRO: This is a patient with high-risk prostate cancer. It’s a 74-year-old gentleman with a history of chronic prostatitis. His PSA [prostate-specific antigen] was 6.5 ng/ml, and a biopsy was done, and it showed prostate adenocarcinoma Gleason score of 8 with perineural invasion. An MRI was done and showed a 0.9 cm lesion, a technetium-99m bone scan was done, and that showed a focal radiotracer in the lateral left 9th rib. It’s important for the audience that when you see things on bone scan, it should also correlate that with a clinical question, which is, did you ever fall? Did you ever break something? Do you ever have an issue? He had a CT [scan], which showed a nonaggressive appearing reticular density in the left 9th rib. Most compatible with a benign fibro-osseous lesion, which he happened to be told about years before. Now, what are you going to do for this guy? Would you also order a PSMA [prostate-specific membrane antigen] PET [positron emission tomography]?

Neal Shore, MD, FACS: Mike, what would you do here? I’m thinking yes, but I’ll defer to your experience.

Michael Gorin, MD: I would’ve started with the PSMA PET and foregone the technetium-99m bone scan and the CT because in the NCCN [National Cancer Comprehensive Network] guidelines it now states that you do not require conventional imaging prior to triggering ordering a PSMA PET scan. For me, high-risk disease equals reflexive PSMA-PET scan. But in this case, given what we know, certainly, I would order a PSMA-PET scan in this context as well.

Lawrence Saperstein, MD: It brings up a great point of educating the community who’s going to be ordering these scans because it looks like we’re falling back into the conventional workup of a CT and a bone scan in this patient. And we can look at the pictures and see what we see.

Neal Shore, MD, FACS: But that’s an important point. Take-home message. And now that the guidelines are saying that you do not have to get conventional CT scan and technician bone scan prior to getting a PSMA PET, I think we all agree with that.

Transcript edited for clarity.