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An Update on Radiographic Imaging for Detecting and Staging Prostate Cancer, Evaluating Treatment Response, and as a Prognostic and Predictive Biomarker

Phillip Koo | April 01, 2022

Effective prostate cancer treatment relies on accurate disease detection and staging. For this reason, recent improvements in localized and whole-body imaging will transform management. The discussion regarding localized disease continues to focus on prostate MRI. For metastatic disease, there is a palpable excitement following the U.S. Food and Drug Administration (FDA) approval of PSMA PET diagnostic agents. These technologies are clearly disruptive. However, this disruption will lead to better informed treatment decisions and ultimately, better outcomes. This article provides an update on radiographic imaging for detecting and staging prostate cancer, evaluating treatment response, and as a prognostic and predictive biomarker.

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Phillip J. Koo, MD, FACS

Phillip J. Koo, MD is the Division Chief of Diagnostic Imaging at the Banner MD Anderson Cancer Center in Arizona. Prior to this, he was Chief of Nuclear Medicine and Associate Professor of Radiology at the University of Colorado School of Medicine. He is a diplomate of both the American Board of Radiology (ABR) and American Board of Nuclear Medicine and is the Chair of the Quality and Evidence Committee for the Society of Nuclear Medicine and Molecular Imaging.

Videos
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Clinical Conversations by Experts
Smarter Screening In Prostate Cancer - Sigrid Carlsson
First Standardized Framework Measuring PSMA PET/CT Response in Metastatic Castration‑Resistant Prostate Cancer - Wolfgang Fendler and Andrei Gafita
Future Perspectives in Prostate Imaging in Developing Countries - Ronaldo Hueb Baroni
PSMA PET CT Derived Risk-Stratification Tool for High-risk Prostate Cancer - a UroToday Journal Club - Christopher Wallis & Zachary Klaassen
Radiotherapy Guided by PSMA PET Molecular Imaging - Juan Galvis Serrano
Higher Rates of Metastatic Disease on PSMA PET for Biochemical Recurrence Risk Groups, Journal Club - Christopher Wallis & Zachary Klaassen
Results from the Phase 3 SPOTLIGHT Trial of 18F-rhPSMA-7.3 in Recurrent Prostate Cancer - David Schuster
Clinical Trial Equity in Radionuclide Treatment for Prostate Cancer - Joseph Osborne
PSMA PET/CT Imaging Indications in Prostate Cancer - Phillip Koo, Neal Shore, & Oliver Sartor
NCCN Guidelines On PSMA Molecular Imaging - Tanya Dorff
PSMA Imaging - Is Conventional Imaging Obsolete - Steven Rowe
Understanding Physiological PSMA Biodistribution - Jeremie Calais
Practical Application of 18F-DCFPyL-PET/CT in Patients with Biochemically Recurrent Prostate Cancer: The CONDOR Study - Michael Morris
18F-DCFPyL PET/CT Imaging in Patients with Suspected Recurrence of Prostate Cancer (CONDOR) Journal Club - Christopher Wallis & Zachary Klaassen
PYLARIFY®, F 18-labeled PSMA Targeted PET Gains US FDA Approval - Michael Morris
The Impact on Patient Care and Clinical Outcomes Gallium 68 PSMA-11 in Suspected Prostate Cancer Metastasis - Jeremie Calais
68Ga-PSMA-11 PET approved in Biochemical Recurrent Prostate Cancer - Jeremie Calais
68Ga-PSMA-11 Joins FDA-Approved Tools for Management of Prostate Cancer - Thomas Hope
Changing the Standard of Care in Prostate Cancer with Advances in Nuclear Medicine, PET and Theranostics Symposium - Rob Flavell
CONDOR: Study of 18F-DCFPyL PET/CT Imaging in Patients with Suspected Recurrence of Prostate Cancer - Michael J. Morris
PSMA PET/CT Imaging for Staging High-risk Prostate Cancer Prior to Curative-intent Surgery or Radiotherapy (proPSMA) - Michael Hofman and Declan Murphy
PSMA PET Diagnostic Imaging in the Current Era - Jeremie Calais
Imaging and Flare Responses When Assessing Patients with Metastatic Castration-Resistant Prostate Cancer - Anwar Padhani
Initial Experience with Actinium- 225 PSMA in Advanced Prostate Cancer - Machaba Michael Sathekge
Advances in PSMA-directed Radionuclide Therapy - Howard Soule
The Use of Novel Imaging Methods in Prostate Cancer - Stefano Fanti
Insights on Nuclear Imaging for Prostate Cancer- Stefano Fanti
Incorporate Next Generation Imaging Tools Into Clinical Practice - Piet Ost
177LU-PSMA-617 in the Treatment of Patients with Progressive PSMA-Positive Metastatic Castration-Resistant Prostate Cancer - Oliver Sartor
A Study of 177Lu-PSMA-617 In Metastatic Castrate-Resistant Prostate Cancer - The VISION Trial, Interview with Oliver Sartor
Advantages of PSMA PET in APC Imaging Presentation - Stefano Fanti
PSMA PET CT, A Mixed Blessing - Interview with Ian Davis
Gold Nanoparticles Used in Photothermal Therapy for Prostate Tumors- Art Rastinehad
Imaging Bone (Flare) Responses in Advanced Prostate Cancer Presentation - Anwar Padhani
Credentialing Imaging as an Outcome Measure in Prostate Cancer - Lawrence H. Schwartz and Michael J. Morris
SNMMI Osseous Scintigraphy - Ephraim E. Parent
Case-based Approaches: PSMA and Personalized Prostate Cancer Care - Frankis Almaguel
Bombesin - A New Frontier for Prostate Cancer Imaging - Andrei Iagaru
A Study Evaluating Optimal Use of Radioactive Drugs for Prostate Cancer Therapy - Misha Beltran
PSMA Theranostics and Personalized Prostate Cancer Care- Frankis Almaguel
Focal Therapy - Art Rastinehad
Prostate Cancer Diagnosis and Treatment: Incorporating New PET imaging and Theranostic Approaches - Robert Flavell
Theranostic Approaches for Advanced Prostate Cancer - Michael Hofman
3D Prostate Gland Uptake of 18F Choline PET CT - Association with Overall Survival in Patients with Hormone-naive Prostate Cancer - May Sadik
Introducing TIN 117m for Convention Electron Therapy of mCRPC - Suresh Srivastava
18F Fluorocholine PET-Whole Body MR in the Staging of High Risk Prostate Cancer - Ur Metser
68Ga PSMA 11 PET MRI in Intermediate and High Risk Prostate Cancer - Claudia Zacharias
Incremental Value of 11C Acetate Over 68Ga-PSMA PET CT for Prostate Cancer Patients - Sirong Chen
Diagnostic Imaging and Therapeutic Aspect of PSMA in Prostate Cancer by Michael Hofman
A Review of Imaging Modalities in Prostate Cancer - Peter Pinto
PSMA Imaging and Theranostics: Future Impact to Patient Management– Robert Flavell
Nuclear Medicine and Lutetium 177 PSMA Therapies - Carmel Pezaro
Imaging Modality and Recommendations Included in RADAR 3: Interview with Phillip Koo
The Incredible Shrinking nmCRPC - Phillip Koo
Physician-Scientist Review Articles
State of the Evidence Review Articles
Written by Christopher J.D. Wallis, MD, PhD, & Zachary Klaassen, MD, MSc
June 22, 2021
An accurate assessment of the extent of disease is critical to the care of patients with cancer, across the natural history of disease including initial evaluation, following local treatment, and assessing response to systemic therapy. Thus, improvements in radiographic imaging may revolutionize
Written by Christopher J.D. Wallis, MD PhD and Zachary Klaassen, MD MSc
April 15, 2021
Prostate-specific membrane antigen (PSMA) is a type II transmembrane glycoprotein which functions as a zinc metalloenzyme and is found on prostatic epithelium. In normal prostate tissue, PSMA expression and localization focuses on the cytoplasm and apical side of the epithelium surrounding prostatic ducts.
May 20, 2020
The purpose of this document is to describe the appropriate use of imaging in the diagnostic evaluation of patients with BCR after definitive primary treatment. The imaging modalities that were considered included CT, bone scan, and the U.S. Food and Drug Administration (FDA)–approved PET radiotracers that track malignancy-induced lipogenesis (11C-choline) and amino acid metabolism (18F-fluciclovine). 
Conference Coverage
Conference Highlights Written by Physician-Scientist
Presented by Thomas A. Hope, MD
(UroToday.com) At the 2022 American Society of Clinical Oncology Annual Meeting held in Chicago and virtually, a breakout session assessing the best approaches and treatment updates in biochemically recurrent prostate cancer featured a presentation from Dr. Thomas A. Hope discussing the manner in which molecular-based imaging is defining the landscape of prostate cancer.
Presented by William J. Aronson, MD
In a podium presentation at the Friday morning plenary of the 2022 American Urologic Association Annual Meeting held in New Orleans and virtually, Dr. William Aronson presented a State-of-the-Art Lecture on prostate specific membrane antigen (PSMA) Diagnostics and Theranostics.
Presented by Michael Hofman, MBBS (Hons), FRACP, FAANMS, FICIS
The 2022 Advanced Prostate Cancer Consensus Conference (APCCC) Hybrid Meeting included a session on the management of metastatic hormone sensitive prostate cancer (mHSPC) and a presentation by Dr. Michael Hofman discussing how frequent low-volume disease on conventional imaging becomes high-volume on next-generation imaging. Dr. Hofman started his presentation by noting that there has been an explosion of PSMA PET publications per year from 2001 to 2021:
Presented by Michael Morris, MD
The 2022 Advanced Prostate Cancer Consensus Conference (APCCC) Hybrid Meeting included a session on the management of non-metastatic castrate-resistant prostate cancer (nmCRPC), and a presentation by Dr. Michael Morris discussing the advantages of using novel imaging in this disease space.
Presented by Ken Herrmann, MD, MBA
The 2022 Advanced Prostate Cancer Consensus Conference (APCCC) Hybrid Meeting included a session on high-risk and locally advanced prostate cancer and a presentation by Dr. Ken Herrmann discussing the impact of next generation imaging and the optimal tracer for PET-based imaging for staging.
Presented by Jason Efstathiou, MD
The 2022 Advanced Prostate Cancer Consensus Conference (APCCC) Hybrid Meeting included a session on high-risk and locally advanced prostate cancer and a presentation by Dr. Jason Efstathiou arguing for changes in management based on next-generation imaging.
Presented by Gerald L. Andriole, Jr, MD
The SUO annual meeting included a prostate cancer session and a presentation by Dr. Gerald Andriole discussing the impact of 18F-fluciclovine PET/CT on plans for ADT in patients with biochemical recurrence of prostate cancer. 
Presented by Robert Reiter, MD
The SIU 2021 annual meeting focused on the role of prostate-specific membrane antigen (PSMA) and theranostics in prostate cancer, Dr. Robert Reiter began with a presentation on the role of PSMA-based imaging as a diagnostic tool in the initial staging of patients with prostate cancer.
Presented by Ephraim E. Parent, MD
In a special session of the ASTRO and SNMMI held at the 2021 ASTRO Annual Congress, Dr. Parent presented on the role of molecular imaging and targeted radionuclide therapy using PSMA-based radiopharmaceuticals.
Presented by Bital Savir-Baruch, MD
In a special session of the American Society for Radiation Oncology (ASTRO) and Society of Nuclear Medicine and Molecular Imaging (SNMMI) held at the 2021 ASTRO Annual Congress, Dr. Baruch presented on the role of molecular imaging using Fluciclovine PET imaging.
Presented by Alberto Bossi, MD
Dr. Alberto Bossi discussed radiotherapy after radical prostatectomy in the PSMA-PET era. Adjuvant radiotherapy is defined as immediate postoperative radiation in the case of extraprostatic extension, positive margins, seminal vesicle infiltration, high Gleason score, or pN+ disease. Salvage radiotherapy is defined as a wait-and-see policy in that radiation is only given in the case of a rising postoperative PSA.
Presented by obias Maurer, MD
The treatment for metastatic hormone-sensitive prostate cancer plenary session at the European Association of Urology 2021 Meeting included a presentation by Dr. Tobias Maurer discussing the role of imaging-guided surgical treatment for recurrent metastatic hormone sensitive prostate cancer (mHSPC).
Presented by Karim Fizazi, MD, Ph.D
Dr. Karim Fizazi finished off the thematic session of Treatment Sequencing in Metastatic Prostate Cancer with a presentation on the role of PSMA in diagnostics and treatment of metastatic prostate cancer.
Presented by Michael S. Hofman, MBBS (Hons), FRACP, FAANMS,
The game changing session of the European Association of Urology (EAU)’s 2021 annual meeting included a presentation by Dr. Michael Hofman from the Peter MacCallum Cancer Centre discussing the phase 2 trial of 177Lu-PSMA-617, TheraP, as well as important contrasts/differences between TheraP and VISION.
Presented by Johann De Bono, MD, MSc, Ph.D., FRCP, FMedSci
The EAU 2021 Annual Meeting included a presentation by Johann De Bono discussing the VISION trial, a phase 3 study of 177Lu-PSMA-617 in patients with mCRPC. As PSMA is highly expressed in prostate cancer and mCRPC lesions, the combination of PSMA-617 with the beta-emitter lutetium allows for the targeted delivery of ß-particle radiation to PSMA-expressing cells and the surrounding microenvironment.
Presented by Mary-Ellen Taplin, MD
Following Micheal Morris’s presentation of the results of the phase III VISION trial of lutetium-177-PSMA-617 in patients with metastatic castration-resistant prostate cancer in the Plenary Session of the 2021 ASCO, Dr. Mary-Ellen Taplin from the Dana Farber Cancer Institute provided a discussant overview of these data and helped to contextualize how we may apply them to our practices.
Presented by Micheal Morris, MD
In a plenary presentation at the 2021 ASCO Annual Meeting, Dr. Morris presented the first results of the VISION trial, a phase III study assessing lutetium-177-PSMA-617 in patients with metastatic castration-resistant prostate cancer.
Presented by Mike Machaba Sathekge, MD, Ph.D
In a plenary presentation in the Progress and Promise in Treatment Personalization for Advanced Prostate Cancer session at the 2021 American Society of Clinical Oncology Genitourinary (Cancers Symposium (ASCO GU), Dr. Sathekge provided a talk examining the role of Lutetium in prostate cancer.
Presented by James Wysock, MD, MSc
At the Society of Urologic Oncology (SUO) Annual Meeting, Dr. James Wysock gave an update on the imaging for primary prostate cancer. Dr. Wysock briefly touched on imaging strategies in both the screening and diagnosis of localized prostate cancer.
Presented by Matthew R. Cooperberg, MD, MPH and Tanya B. Dorff, MD
To conclude the advances in prostate cancer session Drs. Matthew Cooperberg and Tanya Dorff debated whether prostate-specific membrane antigen (PSMA) imaging should be routinely used in the clinical management of prostate cancer.
Presented by Declan Murphy, MB, BCH, BaO, FRACS, FRCS, Urol
At the 2020 virtual Society of Urologic Oncology's (SUO) prostate cancer session, Dr. Declan Murphy discussed the role of prostate-specific membrane antigen (PSMA) scanning in prostate cancer staging. Dr. Declan Murphy states that PSMA PET/CT is an obvious challenger to conventional imaging.
Presented by Declan Murphy, MB, BCH, BaO, FRACS, FRCS, Urol
(UroToday.com) During the Individualized Approach in Advanced Prostate Cancer session at the European Multidisciplinary Congress on Urological Cancers (EMUC) 2020 virtual meeting, Dr. Declan Murphy presents on using prostate-specific membrane antigen (PSMA) positron emission tomography (PET) for upfront staging in high-risk prostate cancer disease. Dr. Murphy states that PSMA PET/CT is an obvious challenger to conventional imaging.
Presented by Renu Eapen, MD
The Société Internationale d'Urologie (SIU) 2020 Virtual Annual Congress featured a debate discussing imaging definitions for oligometastatic prostate cancer. Dr. Renu Eapen from Australia argued that oligometastatic disease should be defined based on novel imaging modalities.
Presented by Noel William Clarke, MD
The Société Internationale d'Urologie (SIU) 2020 Virtual Annual Congress featured a debate discussing imaging definitions for oligometastatic prostate cancer. Dr. Noel Clarke from the United Kingdom argued that oligometastatic disease should be defined based on standard imaging modalities.
Presented by Michael S. Hofman, MBBS (Hons), FRACP, FAANMS,
(UroToday.com) As part of the “Game-Changing Session 1” plenary presentation at the 2020 European Association of Urology (EAU) Virtual Annual Meeting, Dr. Michael Hofman presented results of the proPSMA study which was recently published in the Lancet.1
Presented by Scott T. Tagawa, MD, MS, FACP
There are currently significant imaging deficiencies for men with prostate cancer (Figure 1), with the hope that PSMA imaging-based modalities will address a significant gap in this field. Prostate-specific membrane antigen PSMA is a transmembrane glycoprotein with folate hydrolase activity.
Presented by Michael J. Morris, MD
Men with biochemically recurrent prostate cancer after definitive local therapy currently have limited imaging modalities in the United States which are sensitive or specific enough to detect tumor recurrence. PSMA PET scans can improve on this detection by detecting cells expressing PSMA protein on their cell surface.
Presented by Charles J. Ryan, MD, & Markus Graefen, MD
San Francisco, California (UroToday.com)  The first case presented was that of a 54-year-old otherwise healthy man who underwent radical prostatectomy after biopsy-confirmed prostate cancer.
Presented by Jeremie Calais, MD
San Francisco, California (UroToday.com) Advanced imaging is increasingly being used across all stages of prostate cancer. Dr. Jeremie Calais from UCLA Medical Center discussed
Presented by Claire M. De La Calle, MD
Washington, DC (UroToday.com) While PSA screening has resulted in decreasing prostate cancer mortality, PSA is also known to be a poorly specific test for the detection of clinically
Presented by Renu Eapen, FRACS
Athens, Greece (UroToday.com) Dr. Renu Eapen gave an overview of the role of PET- prostate-specific membrane antigen (PSMA) in prostate cancer and gave a preview of what is to come
Presented by Sigrid Carlsson, MD, PhD, MPH
Athens, Greece (UroToday.com) Dr. Carlsson gave an encompassing presentation on prostate cancer screening from the perspective of an epidemiologist.
Presented by Cora Sternberg, MD
Barcelona, Spain (UroToday.com)  Dr. Cora Sternberg summarized the findings from several posters, including three immunotherapy phase 1 or 2 trials, a phase 2 trial of 177Lu-PSMA-617,
Presented by Scott T. Tagawa, MD, MS
Barcelona, Spain (UroToday.com) PSMA is overexpressed in prostate cancer with limited expression in other organs. Furthermore, prostate cancer is radiosensitive with dose-response (
Presented by Stefano Fanti, MD
Barcelona, Spain (UroToday.com) Theranostics is an emerging field of medicine which utilizes targeted cancer therapy based on specific molecular-targeted diagnostic tests. As part of the Imaging in Prostate Cancer plenary session at the 2019 European Association of Urology (EAU) annual meeting in Barcelona, Spain
Presented by Olivier Rouvière, MD, PhD
Barcelona, Spain (UroToday.com) Dr. Rouviere presented the imaging specialist’s perspective on MRI use in prostate cancer. According to the European Association of Urology (EAU) guidelines prostate multiparametric MRI (mpMRI) was originally recommended after a negative prostate biopsy
Presented by Michael Hofman, FRACP, MBBS

San Francisco, CA (UroToday.com) PSMA is over-expressed in all prostate tissue, including prostatic carcinoma. Lutetium-177 (177Lu)-PSMA617 (LuPSMA) is a small radiolabeled molecule which binds to PSMA

Presented by Jeremie Calais, MD, MSc
San Francisco, CA (UroToday.com)  Salvage radiotherapy (SRT) for prostate cancer biochemical recurrence after radical prostatectomy (RP) is commonly administered to patients with PSA < 1 ng/mL, a threshold at which standard-of-care imaging 
Presented by Paul L. Nguyen, MD
Prague, Czech Republic (UroToday.com) Dr. Paul Nguyen took the stance for radiation therapy in this much-anticipated debate regarding appropriate local treatment in men with high risk localized prostate cancer. Dr. Nguyen notes that high-quality radiation therapy for high-risk disease needs long-term ADT and a brachytherapy boost.
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