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The aim of this guideline is to provide standards for the recommendation, performance, interpretation and reporting of Ga-PSMA PET/CT for prostate cancer imaging. These recommendations will help to improve accuracy, precision, and repeatability ofGa-PSMA PET/CT for prostate cancer essentially needed for implementation of this modality in science and routine clinical practice.

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In prostate cancer with biochemical failure after therapy, current imaging techniques have a low detection rate at the prostate-specific antigen (PSA) levels at which targeted salvage therapy is effective. 11 C-choline and 18 F-fluoromethylcholine, though widely used, have poor sensitivity at low PSA levels. 68 Ga-PSMA (Glu-NH-CO-NH-Lys-(Ahx)-[ 68 Ga-N,N′-bis[2-hydroxy-5-(carboxyethyl) benzyl]ethylenediamine-N,N′-diacetic acid]) has shown promising results in retrospective trials. Our aim was to prospectively compare the detection rates of 68 Ga-PSMA versus 18 F-fluoromethylcholine PET/CT in men who were initially managed with radical prostatec-tomy, radiation treatment, or both and were being considered for targeted therapy. Methods: A sample of men with a rising PSA level after treatment, eligible for targeted treatment, was prospectively included. Patients on systemic treatment were excluded. 68 Ga-PSMA, 18 F-fluoromethylcholine PET/CT, and diagnostic CT were performed sequentially on all patients between January and April 2015, and the images were assessed by masked, experienced interpreters. The findings and their impact on management were documented, together with the results of histologic follow-up when feasible. Results: In total, 38 patients were enrolled. Of these, 34 (89%) had undergone radical prostatectomy and 4 (11%) had undergone radiation treatment. Twelve (32%) had undergone salvage radiation treatment after primary radical prostatectomy. The mean PSA level was 1.74 ± 2.54 ng/mL. The scan results were positive in 26 patients (68%) and negative with both tracers in 12 patients (32%). Of the 26 positive scans, 14 (54%) were positive with 68 Ga-PSMA alone, 11 (42%) with both 18 F-fluoromethylcholine and 68 Ga-PSMA, and only 1 (4%) with 18 F-fluoromethylcholine alone. When PSA was below 0.5 ng/mL, the detection rate was 50% for 68 Ga-PSMA versus 12.5% for 18 F-fluoromethylcholine. When PSA was 0.5-2.0 ng/mL, the detection rate was 69% for 68 Ga-PSMA versus 31% for 18 F-fluoromethylcholine, and when PSA was above 2.0, the detection rate was 86% for 68 Ga-PSMA versus 57% for 18 F-fluoromethylcholine. On lesion-based analysis , 68 Ga-PSMA detected more lesions than 18 F-fluoromethylcholine (59 vs. 29, P , 0.001). The tumor-to-background ratio in positive scans was higher for 68 Ga-PSMA than for 18 F-fluoromethylcholine (28.6 for 68 Ga-PSMA vs. 9.4 for 18 F-fluoromethylcholine, P , 0.001). There was a 63% (24/38 patients) management impact, with 54% (13/24 patients) being due to 68 Ga-PSMA imaging alone. His-tologic follow-up was available for 9 of 38 patients (24%), and 9 of 9 68 Ga-PSMA-positive lesions were consistent with prostate cancer (68 Ga-PSMA was true-positive). The lesion positive on 18 F-fluoromethylcholine imaging and negative on 68 Ga-PSMA imaging was shown at biopsy to be a false-positive 18 F-fluoromethylcholine finding (68 Ga-PSMA was true-negative). Conclusion: In patients with biochemical failure and a low PSA level, 68 Ga-PSMA demonstrated a significantly higher detection rate than ...

Contrast-enhanced computed tomography (CT) of the neck-thorax-abdomen and pelvis, including 3-phase examination of the liver, constitutes the basic imaging for primary neuroendocrine tumor (NET) diagnosis, staging, surveillance, and therapy monitoring. CT characterization of lymph nodes is difficult because of inadequate size criteria (short axis diameter), and bone metastases are often missed. Contrast-enhanced magnetic resonance imaging (MRI) including diffusion-weighted imaging is preferred for the examination of the liver, pancreas, brain and bone. MRI may miss small lung metastases. MRI is less well suited than CT for the examination of extended body areas because of the longer examination procedure. Ultrasonography (US) frequently provides the initial diagnosis of liver metastases and contrast-enhanced US is excellent to characterize liver lesions that remain equivocal on CT/MRI. US is the method of choice to guide the biopsy needle for the histopathological NET diagnosis. US cannot visualize thoracic NET lesions for which CT-guided biopsy therefore is used. Endocopic US is the most sensitive method to diagnose pancreatic NETs, and additionally allows for biopsy. Intraoperative US facilitates lesion detection in the pancreas and liver. Somatostatin receptor imaging should be a part of the tumor staging, preoperative imaging and restaging, for which ⁶⁸Ga-DOTA-somatostatin analog PET/CT is recommended, which is vastly superior to somatostatin receptor scintigraphy, and facilitates the diagnosis of most types of NET lesions, for example lymph node metastases, bone metastases, liver metastases, peritoneal lesions, and primary small intestinal NETs. ¹⁸FDG-PET/CT is better suited for G3 and high G2 NETs, which generally have higher glucose metabolism and less somatostatin receptor expression than low-grade NETs, and additionally provides prognostic information.

The second Advanced Prostate Cancer Consensus Conference APCCC 2017 did provide a forum for discussion and debates on current treatment options for men with advanced prostate cancer. The aim of the conference is to bring the expertise of world experts to care givers around the world who see less patients with prostate cancer. The conference concluded with a discussion and voting of the expert panel on predefined consensus questions, targeting areas of primary clinical relevance. The results of these expert opinion votes are embedded in the clinical context of current treatment of men with advanced prostate cancer and provide a practical guide to clinicians to assist in the discussions with men with prostate cancer as part of a shared and multidisciplinary decision-making process.

The aim of these guidelines is to assist nuclear medicine physicians in recommending, performing, reporting and interpreting the results of somatostatin (SST) receptor PET/CT imaging using 68Ga-DOTA-conjugated peptides, analogues of octreotide, that bind to SST receptors. This imaging modality should not be regarded as the only approach to visualizing tumours expressing SST receptors or as excluding other imaging modalities useful for obtaining comparable results. The corresponding guidelines of 111In-pentetreotide scintigraphy imaging have been considered and partially integrated with this text. The same has been done with the relevant and recent literature in this field and the final result has been discussed by distinguished experts.