Theranostics for prostate cancer: A Canadian, multidisciplinary expert report
DOI:
https://doi.org/10.5489/cuaj.10062Keywords:
theranostics, prostate cancer, PSMA PET/CT, RLTAbstract
Introduction: Prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) and PSMA radioligand therapy are changing prostate cancer management, but there is ongoing uncertainty regarding how best to incorporate these approaches into routine practice. This expert report provides Canadian multidisciplinary consensus guidance on PSMA PET/CT, interpretation of selected imaging findings, and use of lutetium-177-PSMA-617 (177Lu-PSMA-617) in areas of clinical uncertainty.
Methods: A Canadian panel of urologic oncologists, medical oncologists, radiation oncologists, and nuclear medicine specialists participated in a modified Delphi process. Clinical questions were developed, refined through panel review, discussed at a consensus meeting, and voted on anonymously. Consensus was predefined as agreement of ≥80%.
Results: Consensus was achieved for 59% of clinical questions and 87% of nuclear medicine questions. The panel supported PSMA PET/CT with magnetic resonance imaging (MRI) for staging of high-risk and very high-risk localized prostate cancer, emphasized that negative PSMA PET/CT should not rule out indicated prostate bed or pelvic nodal treatment, and provided direction on PSMA PET/CT in biochemical recurrence, oligometastatic disease, and advanced disease. Consensus statements on 177Lu-PSMA-617 addressed sequencing with radium-223 (223Ra), patient selection in cases of bone marrow or renal impairment, treatment monitoring, completion of planned treatment in responders, and palliative radiotherapy for symptomatic metastases. Nuclear medicine guidance focused on risk-adapted interpretation of solitary PSMA-avid lesions, common false-positive patterns, rib lesions, and selected use of delayed imaging.
Conclusions: These consensus statements provide practical Canadian guidance for integrating theranostics into prostate cancer care. Multidisciplinary decision-making, careful image interpretation, and avoidance of overreliance on a solitary imaging finding remain essential.
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