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  • Prostate Cancer

Revolutionizing Prostate Cancer Imaging: Traditional Techniques vs. PSMA-PET


In this introductory dialogue, Naveen Kella, MD, and Dr. Shadi Esfahani, MD, MPH, discuss PSMA-PET's transformative role alongside conventional techniques in prostate cancer imaging.


Naveen Kella, MD: I’m Dr [Naveen] Kella. Happy to talk to with Dr [Shadi Abdar] Esfahani about PSMA [prostate-specific membrane antigen] PET/CT imaging. Dr Esfahani, can you give us a brief historical perspective on conventional imaging for prostate cancer?

Shadi Abdar Esfahani, MD, MPH: Hi there. Thank you very much for inviting me…. In terms of the conventional imaging for [treating] patients with prostate cancer, traditionally, or at least in the past decade…it’s been very common that we start with a multiparametric MRI for initial evaluation of the prostate gland itself…and possibly for more directed tissue sampling for the initial diagnosis of the prostate cancer. Obviously, if there is a concern or if there is a biopsy-proven cancer, there will be the use of the diagnostic CT [scan] of the abdomen and pelvis at least, and…for a complete staging, other parts of the body as well. Bone scan has always been used in the past couple of decades for evaluation of the bone metastases, since [it] is very common for patients’ prostate cancer to metastasize to the bones. In terms of the general use of these conventional imaging modalities, they are still around, and everybody still uses all of these.

Naveen Kella, MD: That’s great. With conventional imaging, are you seeing limitations or clinical challenges? Speaking to the different types of imaging modalities you just reviewed, what are your thoughts?

Shadi Abdar Esfahani, MD, MPH: I would say the answer to this question is now much easier in retrospect because we have the PSMA-targeted PET imaging for both the initial diagnosis of the initial site of the disease in the prostate gland and also in different parts of the body. I would say now that we know how much we have missed with the diagnostic CTs and also possibly with the bone scans…the management completely changes. Before the PSMA PET [scan] and how the radiologists evaluate the conventional imaging, let’s say the CT of the abdomen and pelvis was read, and if we had seen, for example, sub-centimeter lymph nodes, we would just ignore them completely. And we would say, if the node is below 1 cm, there’s no metastasis in the abdomen or pelvis, for example. Or if there was a very tiny bone lesion, we would just say this is indeterminate, follow it up, and compare it with the other imaging modalities to see what it is. Or possibly, we had to biopsy them because we couldn’t really make any decision based on this small size.

Now that we have the PSMA PET [scan], we understand that the tiniest nodes, the tiniest lesions, can have uptake and can be sites of primary or metastatic disease. And also based on the PET [scan], we know that sometimes we see areas of uptake, for example, in the bones or in the liver or other places. And we know that based on the degree of uptake and how it’s shown on the PET [scan], these are sites of disease, but there may not be a definite correlate [of] them on the diagnostic CTs, for example, or on the bone scan. So I would say that in terms of the sensitivity and specificity, there are certain limitations to the diagnostic imaging, although I wouldn’t say that PET completely replaces the diagnostic and conventional imaging that we’ve been using. But now the interpretation of the findings is changing the way that radiologists think. [It] is very different now because we know that size or having a definite correlate…is not really needed for all of the diagnostic matters.

Naveen Kella, MD: That’s great.

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

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