Naveen Kella, MD, and Dr. Shadi Esfahani, MD, MPH, discuss the consensus between clinical guidelines for PSMA PET CT usage in prostate cancer, emphasizing multidisciplinary collaboration and the importance of urologists' involvement.
Shadi Abdar Esfahani, MD, MPH: The other question I had [for] you, Dr Kella, is…in terms of [how] there are so many clinical guidelines right now. Do you think that they are…overall in general agreement with each other…in terms of the use of PSMA [prostate-specific membrane antigen] PET [positron emission tomography] in prostate cancer? Is there any specific recommendation that differentiates between the gallium 68– and F18–labeled radiotracers right now? I know that there's also…the American [guidelines], the outside American society guidelines, and the joint guidelines of EANM [European Association of Nuclear Medicine] and Society of Nuclear Medicine. So, I wanted to get your insights and pick your brain on that.
Naveen Kella, MD: From the urology perspective, I would agree with what you'd said earlier that really, there aren't substantial differences that we know of right now between the different…2 widely available PSMA PET-CT tracers with gallium  and fluorine . So, as far as using…PSMA PET-CT for our patients, again...with the NCCN [National Comprehensive Cancer Network] guidelines coming out strongly suggesting usage in appropriate patients as frontline therapy, we're ordering PSMA PETs and...that's really going to change things, even though the test has just been around for a year. It may even replace conventional imaging for a large part of when we screen for our patients. Would you agree or what do you think?
Shadi Abdar Esfahani, MD, MPH: I do. I agree. It seems that based on the current guidelines, they are all in agreement for the general use of the PSMA PET and the indications and the patient groups and populations who would benefit and the situations that they would benefit [in]. I don't think there is a major suggestion…or any kind of specific difference between the two compounds. As you mentioned in the most recent guideline, it was a joint guideline by EANM and SNM [Society of Nuclear Medicine]. There is a very good section about the overall pitfalls of both compounds and how we need to be more aware of the situations that a lesion or a finding can be indeterminate or can be a false positive. And we need to make sure that…our radiologists and nuclear medicine physicians have enough information and also guidance and the background knowledge on how to differentiate these and how to interpret the findings, specifically for some of the benign lesions.
For example, some of the bone uptake—like isolated bone lesions, for example—or in majority of the cases, I wouldn't say at all…And also like the ganglia, for example…most of the time they can have uptake. So…these were just 2 examples, but in general, there are some benign findings or…just based on the general biodistribution of the compounds, we just need to know what is not a positive or a certainly positive finding on either of these scans. And we just need to be aware of those situations. So...those sections on the pitfalls are very helpful just in general to be more aware when we are interpreting the findings as the radiologists and nuclear medicine physicians.
Naveen Kella, MD: Right. That's really insightful. I've had some patients, or some radiologist mentioned to me, as you mentioned…the isolated bone lesions. So, I found that really interesting. Maybe as a step back, there's still a lot of work to be done in PET-CT imaging with PSMA. As a urologist...it's really important for urologists to be involved with the PET-CTs, looking at the images yourself and questioning the radiologists, because...it's new for a lot of radiologists as well.
Shadi Abdar Esfahani, MD, MPH: Exactly. This is absolutely a multidisciplinary approach, and it has to be this way so that all of the findings that we have on the PSMA PET-CTs or PET MRIs [magnetic resonance imaging] can be interpreted based on the clinical setting and the indications and the…general patient's condition, rather than just judging them by the imaging only.
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