Here we aim to provide updated guidance and standards for the indication, acquisition, and interpretation of PSMA PET/CT for prostate cancer imaging. Procedures and characteristics are reported for a variety of available PSMA small radioligands. Different scenarios for the clinical use of PSMA-ligand PET/CT are discussed. This document provides clinicians and technicians with the best available evidence, to support the implementation of PSMA PET/CT imaging in research and routine practice. 

/pdf/psma-pet-ct-joint-eanm-procedure-guideline-snmmi-procedure-3vkoeflt.pdf

PSMA PET/CT: joint EANM procedure guideline/SNMMI procedure standard for prostate cancer imaging 2.0

https://doi.org/10.1016/j.eururo.2022.11.002

Management of Patients with Advanced Prostate Cancer. Part I: Intermediate-/High-risk and Locally Advanced Disease, Biochemical Relapse, and Side Effects of Hormonal Treatment: Report of the Advanced Prostate Cancer Consensus Conference 2022

http://www.thegreenjournal.com/article/S0167814022044991/pdf

Recommendations for Radiation Therapy in Oligometastatic Prostate Cancer: an ESTRO-ACROP Delphi consensus.

Introduction: Prostate-specific membrane antigen (PSMA) is a promising novel molecular target for imaging diagnostics and therapeutics (theranostics). There has been a growing body of evidence supporting PSMA theranostics approaches in optimizing the management of prostate cancer and potentially altering its natural history. Methods: We utilized PubMed and Google Scholar for published studies, and clinicaltrials.gov for planned, ongoing, and completed clinical trials in PSMA theranostics as of June 2021. We presented evolving evidence for various PSMA-targeted radiopharmaceutical agents in the treatment paradigm for prostate cancer, as well as combination treatment strategies with other targeted therapy and immunotherapy. We highlighted the emerging evidence of PSMA and fluorodeoxyglucose (FDG) PET/CT as a predictive biomarker for PSMA radioligand therapy. We identified seven ongoing clinical trials in oligometastatic-directed therapy using PSMA PET imaging. We also presented a schematic overview of 17 key PSMA theranostic clinical trials throughout the various stages of prostate cancer. Conclusions: In this review, we presented the contemporary and future landscape of theranostic applications in prostate cancer with a focus on PSMA ligands. As PSMA theranostics will soon become the standard of care for the management of prostate cancer, we underscore the importance of integrating nuclear medicine physicians into the multidisciplinary team.

PSMA Theranostics: Current Landscape and Future Outlook

Visual Abstract 18F-PSMA-1007 PET is used in the management of patients with prostate cancer. However, recent reports indicate a high rate of unspecific bone uptake (UBU) with 18F-PSMA-1007, which may lead to a false-positive diagnosis. UBU has not been evaluated thoroughly. Here, we evaluate the frequency of UBU and bone metastases separately for 18F-PSMA-1007 and 68Ga-PSMA-11 in biochemical recurrence (interindividual comparison). Additionally, we investigate UBU seen in 18F-PSMA-1007 through follow-up examinations (intraindividual comparison) using 68Ga-PSMA-11 PET, bone scintigraphy, and MRI. Methods: First, all patients (n = 383) who underwent 68Ga-PSMA-11 PET between January 2020 and December 2020 and all patients (n = 409) who underwent 18F-PSMA-1007 PET between January 2020 and November 2021 due to biochemical recurrence were included for an interindividual comparison of bone metastases and UBU rate. In a second approach, we regarded all patients with UBU in 18F-PSMA-1007, characterized by focal bone uptake with an SUVmax > 4 and prostate-specific antigen (PSA) ≤ 5 ng/mL, who underwent additional 68Ga-PSMA-11 PET (n = 17) (interindividual comparison). Of these, 12 patients also had bone scintigraphy and whole-body MRI within a 1- to 5-wk interval. Bone uptake seen on 18F-PSMA-1007 but not on any of the other 4 modalities (CT, MRI [n = 1], bone scanning, and 68Ga-PSMA-11 PET) was recorded as false-positive. Results: Patients scanned with 18F-PSMA-1007 PET had a significantly higher rate of UBU than those scanned with 68Ga-PSMA-11 (140 vs. 64; P < 0.001); however, the rate of bone metastases was not significantly different (72 vs. 64; P = 0.7). In the intraindividual comparison group, workup by CT, MRI, bone scanning, and 68Ga-PSMA-11 PET resulted in a positive predictive value for 18F-PSMA-1007 focal bone uptake (mean SUVmax, 6.1 ± 2.9) per patient and per lesion of 8.3% and 3.6%, respectively. Conclusion: In patients with PSA ≤ 5 ng/mL and SUV > 4 at biochemical recurrence, most 18F-PSMA-1007 focal bone uptake is likely to be false-positive and therefore due to UBU. In the case of low clinical likelihood of metastatic disease, 18F-PSMA-1007 bone uptake without morphologic surrogate should be assessed carefully with regard to localization and clinical context. However, the rate of bone metastases was not higher with 18F-PSMA-1007 in the clinical routine, indicating that experienced reporting physicians adjust for UBU findings.

Unspecific 18F-PSMA-1007 Bone Uptake Evaluated Through PSMA-11 PET, Bone Scanning, and MRI Triple Validation in Patients with Biochemical Recurrence of Prostate Cancer

Improved logistics and availability led to a rapid increase in the use of [18F]-PSMA-1007 for prostate cancer PET imaging Initial data suggests increased uptake in benign lesions compared to [68 Ga]-PSMA-11, and clinical observations found increased unspecific bone uptake (UBU) We therefore investigate the frequency and characteristics of UBU in [18F]-PSMA-1007 PET We retrospectively analyzed [18F]-PSMA-1007 PET scans from four centers for the presence of UBU, defined as a focal mild-to-moderate uptake (SUVmax < 100) not obviously related to a benign or malignant cause If present, up to three leading UBUs were quantified (SUVmax), localized, and correlated to clinical parameters, such as age, PSA, injected dose, Gleason score, tumor size (T1–T4), and type of PET scanner (analog vs digital) Additionally, clinical and imaging follow-up results and therapeutic impact were evaluated UBUs were identified in 179 out of 348 patients (514%) The most frequent localizations were ribs (575%) and pelvis (248%) The frequency of UBUs was not associated with PSA, Gleason score, tumor size, age, or the injected [18F]-PSMA-1007 dose UBUs were significantly more frequent in images obtained with digital PET/CT scans (n = 74, 82%) than analog PET/CT scans (n = 221, 403%) (p = 0001) but not in digital PET/MR (n = 53, 51%) (p = 1599) In 80 out of 179 patients (447%), the interpretation of UBUs was critical for therapeutic management and therefore considered clinically relevant For 65 UBUs, follow-ups were available: three biopsies, three radiotherapies with PSA follow-up, and 59 cases with imaging After follow-up, UBUs were still considered unclear in 28 of 65 patients (43%), benign in 28 (43%), and malignant in nine (14%) patients UBUs occur in two-thirds of patients imaged with [18F]-PSMA-1007 PET/CT and are significantly more frequent on digital PET scanners than analog scanners UBUs should be interpreted carefully to avoid over-staging

/pdf/focal-unspecific-bone-uptake-on-18f-psma-1007-pet-a-4x7my8jle6.pdf

Focal unspecific bone uptake on [18F]-PSMA-1007 PET: a multicenter retrospective evaluation of the distribution, frequency, and quantitative parameters of a potential pitfall in prostate cancer imaging

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Focal unspecific bone uptake on [18F]-PSMA-1007 PET: a multicenter retrospective evaluation of the distribution, frequency, and quantitative parameters of a potential pitfall in prostate cancer imaging