Page 4 - The Contemporary Role of Conventional Imaging for Staging, Re-staging, and Monitoring Prostate Cancer: Impact on Management

Table 2. Summary of Recommendations: Primary Staging Before Local Therapies

Indication Modality

APCCC 2017 High-risk or locally-advanced prostate • Combination of CT and bone scan
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cancer: to exclude distant metastases (41% of panel vote)
• PET/CT with any tracer (37% of panel vote)
• WB-MRI (10% of panel vote)
AUA-ASTRO-SUO 2017 11 Unfavourable intermediate-risk disease • Cross-sectional CT (abdopelvic) or MRI
– 2 or more of: (prostate or pelvis)
• Palpable nodule on DRE (T2b/c) • Bone scan
• Gleason 7 (3+4 or 4+3)
• PSA >10 ng/mL
High-risk disease
• PSA >20 ng/mL or
• Grade Group 4-5* or
• Clinical stage >T3

EAU 2018 12 Intermediate-risk disease • Cross-sectional abdopelvic imaging (CT/MRI)
• Predominantly Gleason pattern 4 (≥ ISUP 3) • Bone scan
High-risk localized/high-risk locally-advanced • Prostate multiparametric MRI
NCCN 2018 13 Life expectancy >5 yrs or symptomatic and • Pelvic ± abdominal imaging if nomogram
†
risk group features: predicts>10% probability of lymph node
Favourable intermediate involvement
• T2b-T2c or
• Gleason score 3+4=7* or
• PSA 10-20 ng/mL
and
• % of positive biopsy cores <50%

Life expectancy > 5 yrs or symptomatic • Bone imaging if T2 and PSA >10 ng/mL
†
and risk group features: • Pelvic ± abdominal imaging if nomogram
†
Unfavourable intermediate predicts >10% probability of lymph node
• T2b-T2c or involvement
• Gleason score 3+4=7 or 4+3=7* or
• PSA 10-20 ng/mL

Life expectancy >5 yrs or symptomatic • Bone imaging ‡
and risk group features: • Pelvic ± abdominal imaging if nomogram
†
High predicts >10% probability of lymph node
• T3a or involvement
• Gleason score 8 or 4+5=9* or
• PSA >20 ng/mL
Very high
• T3b-T4 or
• Primary Gleason pattern 5 or
• >4 cores with Gleason score 8-10*

For life expectancy ≤5 yrs and asymptomatic, no further workup or treatment until
symptomatic, except in high or very high-risk groups.

*Grade group 2 = Gleason score 3+4; grade group 3 = Gleason score 4+3; grade group 4 = Gleason score 4+4; grade group 5 = Gleason score 4+5. 11
† NCCN did not specify a nomogram for predicting lymph node involvement.
‡ Plain films, CT, MRI, or F-18 NaF PET/CT can be considered if equivocal results on the initial bone scan.
APCCC = Advanced Prostate Cancer Consensus Conference; ASTRO = American Society for Radiation Oncology; AUA = American Urological Association; DRE = digital rectal
exam; EAU = European Association of Urology; ISUP = International Society of Urological Pathology; NCCN = National Comprehensive Cancer Network; SUO = Society of
Urologic Oncology; WB-MRI = whole-body diffusion weighted magnetic resonance imaging.

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