Prostate-specific membrane antigen positron emission tomography (PSMA-PET) should be performed only in patients with high-risk or unfavorable intermediate-risk prostate cancer staging, according to a recent review published in European Urology Oncology.

Due to its suboptimal sensitivity for lymph node metastasis, it should not be used to avoid pelvic lymph node dissection during radical prostatectomy for primary cancer. It might allow patients to have nerve-sparing surgery, according to Francesco Ceci, MD, PhD, of IEO European Institute of Oncology IRCCS in Milan, Italy, and colleagues.

The investigators performed their comprehensive nonsystematic review in April 2022, with the literature search updated until March 2022.

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PSMA-PET identified metastatic lesions with higher accuracy than computed tomography (CT) or bone scan in both primary and recurrent prostate cancer, the reviewers reported. PSMA-PET identified bone as the most frequent site of metastatic spread during staging (up to 17%) and restaging (up to 18%). PSMA-PET also identified lymph node metastasis outside the pelvis and visceral involvement better than conventional imaging.

PSMA-PET commonly leads to stage migration, most often upstaging. Approximately half of patients who undergo PSMA-PET will have a treatment change, according to Dr Ceci’s team.

In the setting of biochemical recurrence, PSMA-PET staging results may help guide subsequent treatment. For example, results may confirm oligometastatic disease suitable for metastasis directed therapy, permitting a delay in the initiation of androgen deprivation therapy (ADT). The European Association of Urology guidelines recommend performing PSMA-PET at PSA recurrence when results can influence treatment decisions.

“PSMA-PET detects a higher number of lesions than conventional imaging or other PET radiotracers, especially metastatic lesions unseen with other modalities. The high diagnostic accuracy of PSMA-PET leads to a significant patient upstage and thus an impact in clinical management, even if the overall impact on cancer mortality is still to be assessed,” Dr Ceci’s team concluded.


Mattana F, Muraglia L, Raiwa P, et al. Metastatic sites’ location and impact on patient management after the introduction of prostate-specific membrane antigen positron emission tomography in newly diagnosed and biochemically recurrent prostate cancer: a critical review. Eur Urol Oncol. Published online February 16, 2023. doi:10.1016/j.euo.2023.01.014