Version June 2024
| Rising PSA after prostatectomy and negative conventional imaging (either initial PSA undetectable with subsequent rise or PSA never nadirs to undetectable) |
| Recommendation 4.3. Both disease states are indicative of potentially undetected, residual local, locoregional, or micrometastatic disease, and imaging options are not distinct or different between these scenarios. The goal of therapy and the potential use of salvage local therapies in these scenarios should guide the choice of imaging. For men who are not candidates or are unwilling to receive salvage local or regional therapy, additional NGI should not be offered. |
| Recommendation 4.4. For men for whom salvage radiotherapy is contemplated, NGI should be offered (PSMA imaging [where available]; 11C-choline or 18F-fluciclovine PET/CT; or PET/MRI, whole body MRI, and/or 18F-NaF PET/CT) as they have superior disease detection performance characteristics and may alter patient management. |
| Rising PSA after radiotherapy and negative conventional imaging |
| Recommendation 4.5. For men in whom salvage local or regional therapy is not planned or is inappropriate, there is little evidence that NGI will alter treatment or prognosis. The role of NGI in this scenario is unclear and should not be offered, except in the context of an institutional review board-approved clinical trial. |
| Recommendation 4.6. For men for whom salvage local or regional therapy (eg, salvage prostatectomy, salvage ablative therapy, or salvage lymphadenectomy) is contemplated, there is evidence supporting NGI for detection of local and/or distant sites of disease. Findings on NGI could guide management in this setting (eg, salvage local, systemic or targeted treatment of metastatic disease, combined local and metastatic therapy). PSMA imaging (where available), 11C-choline or 18F-fluciclovine PET/CT or PET/MRI, whole body MRI, and/or 18F-NaF PET/CT have superior disease detection performance characteristics compared with conventional imaging and alter patient management, although data are limited. |
| Metastatic prostate cancer at initial diagnosis or after initial treatment, hormone sensitive |
| Recommendation 4.7. In the initial evaluation of men presenting with hormone-sensitive disease with demonstrable metastatic disease on conventional imaging, there is a potential role for NGI to clarify the burden of disease and potentially shift the treatment intent from multimodality management of oligometastatic disease to systemic anticancer therapy alone or in combination with targeted therapy for palliative purposes, but prospective data are limited. |
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