PSMA PET's Expanding Role in Prostate Cancer Imaging

Welcome back to another Urology Times Virtual Tumor Board series. In "PSMA PET's Expanding Role in Prostate Cancer Imaging," moderator Munir Ghesani, MD is joined by Travis Mendel, MD and Paul Yonover, MD to open the series on advanced prostate cancer, tracing how molecular imaging has reshaped staging and treatment planning.

Dr. Ghesani opens by introducing himself as moderator and Chief Medical Officer of United Theranostics, alongside Dr. Mendel, a radiation oncologist practicing in El Paso, Texas, and Dr. Yonover, a urologist and Chief Data Officer at a large single-specialty group in Chicago. Dr. Ghesani reviews decades of imaging advances in prostate cancer, from transrectal ultrasound through CT and bone scans, noting that roughly three years ago the NCCN revised its guidelines to allow PSMA PET without routine conventional imaging beforehand. He explains that CT and bone scans still retain a role in select cases, and that MRI remains essential for local and regional staging. Dr. Yonover describes using MRI almost exclusively before biopsy to guide sampling, then moving directly to PSMA PET for staging in high- and very-high-risk patients, reserving conventional CT for adjudicating ambiguous findings. Dr. Mendel agrees, noting how dramatically PSMA imaging has changed his radiation planning over the past two to three years, and that he now rarely orders conventional imaging outside research protocols or insurer mandates. Both physicians describe MRI's continuing importance for biopsy guidance and treatment planning and note that PET findings sometimes reveal unexpected non-PSMA-avid lesions requiring further workup. Dr. Yonover raises the frequency of incidental findings, such as lung masses or aneurysms, that accompany PSMA PET scanning in this population. Dr. Ghesani adds that PSMA expression is not strictly prostate-specific, with case reports describing incidental detection of other cancers, and cautions that clinicians must distinguish clinically important incidental findings from benign distractions. He then asks the panelists to describe the limitations of conventional imaging they encountered before PSMA PET became routinely available, including difficulty detecting small lymph nodes, multifocal disease, and isodense bone lesions.

The next episode in this series, "PSMA PET Radiotracers and Access Barriers in Prostate Cancer," features the panel detailing the available PSMA radiotracers and the access barriers clinicians face in ordering them.