Appropriate Use Criteria for Prostate-Specific Membrane Antigen PET Imaging

Prostate cancer is the most common cancer diagnosis in men in the United States and a leading cause of cancer-related morbidity and mortality (1). It can exist along a wide spectrum of aggressiveness and severity, from indolent, very-low-risk, localized prostate cancer to life-threatening, very-high-risk, metastatic prostate cancer. For a newly diagnosed patient in a given clinical state, especially early in the disease, the spectrum of appropriate therapeutic options may range from no intervention to multimodality therapy. Accurate assessment of the extent of disease (e.g., metastatic vs. localized prostate cancer) is essential for guiding treatment decisions. Decision making for the clinical use of imaging and for the development of new imaging technology can both be organized by the framing principles outlined in Prostate Cancer Working group 3 (2). Imaging plays a critical role in that assessment, which has traditionally been done in men at high risk for metastatic disease using a 99mTc-methylene diphosphate bone scan and CT (3). Significant advances toward developing more sensitive imaging techniques for detecting the extent of prostate cancer include PET radiopharmaceuticals. Although useful across a wide variety of cancer types, 18F-FDG PET has had limited applicability in prostate cancer staging (4). Novel radiopharmaceuticals such as 18F-fluciclovine and choline PET have been used increasingly in the biochemical recurrence (BCR) setting but have limited specificity