前列腺癌2022.v3（英文）-NCCN肿瘤临床实践指南

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines®)ProstateCancerersionJanuaryNCCNGuidelinesforPatients®availableat/patientsVersion3.2022,01/10/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.manCassPhDdiMScdMS¥§radiologyÞInternalmedicineRadiotherapy/RadiationwUrology*DiscussionmanCassPhDdiMScdMS¥§radiologyÞInternalmedicineRadiotherapy/RadiationwUrology*DiscussionSectionWritingCommittee*EdwardM.Schaeffer,MD,PhD/Chairω*SandySrinivas,MD/Vice-Chair†ωEmmanuelS.Antonarakis,MD†kins*AndrewJ.Armstrong,MD,ScM†HeatherH.Cheng,MD,PhD†SeattleCancerCareAllianceAnthonyVictorD’Amico,MD,PhD§CancerCenter|MassachusettsGeneralHospitalCancerCenterBrianJ.Davis,MD,PhD§NeilDesai,MD,MHS§CenterTanyaDorff,MD†CityofHopeNationalCancerCenterJamesA.Eastham,MDωarringtonXinGao,MD†Dana-Farber/BrighamandWomen'sCancerCenter|MassachusettsGeneralHospitalCancerCenterShilpaGupta,MD†ThomasGuzzo,MDωAbramsonCancerCenteratTheUniversityofPennsylvaniaEricMarkHorwitz,MD§FoxChaseCancerCenter*JosephE.Ippolito,MD,PhDфSitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicineMichaelR.Kuettel,MD,MBA,PhD§lParkComprehensiveCancerCenterJoshuaM.Lang,MD,MS†UniversityofWisconsinCarboneCancerCenterRanaR.McKay,MD†cerCenterToddMorgan,MDωUniversityofMichiganRogelCancerCenterGeorgeNetto,MD≠O'NealComprehensiveCancerCenteratUABDavidF.Penson,MD,MPHωVanderbilt-IngramCancerCenterJulioM.Pow-Sang,MDωMoffittCancerCenterRobertReiter,MD,MBAωUCLAJonssonComprehensiveCancerCenterMackRoach,III,MD§UCSFHelenDillerFamilyCenterTylerRobin,MD,PhD§UniversityofColoradoCancerCenterosenfeldAhmadShabsigh,MDωeCancerCenterJamesCancerHospitalBenjaminA.Teply,MD†Fred&PamelaBuffettCancerCenterJonathanTward,MD,PhD§RichardValicenti,MD§UCDavisComprehensiveCancerCenteresPanelDisclosuresPrintedbyMinTangon3/14/20227:42:44AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexncerPanelMembersSummaryofGuidelinesUpdatesInitialProstateCancerDiagnosis(PROS-1)InitialRiskStratificationandStagingWorkupforClinicallyLocalizedDisease(PROS-2)wRiskGroupPROSLowRiskGroup(PROS-4)FavorableIntermediateRiskGroup(PROS-5)UnfavorableIntermediateRiskGroup(PROS-6)horVeryHighRiskGroupPROSRegionalRiskGroup(PROS-8)MonitoringPROS-9)statectomyPSAPersistenceRecurrencePROS-10)pyRecurrencePROSSystemicTherapyforCastrationNaveProstateCancerPROS-12)SystemicTherapyforMCastrationResistantProstateCancer(CRPC)(PROS-13)SystemicTherapyforMCRPC(PROS-14)rapyforMCRPCAdenocarcinomaPROS-15)ofLifeExpectancyEstimationPROSAPrinciplesofGeneticsandMolecular/BiomarkerAnalysis(PROS-B)PrinciplesofRiskStratification(PROS-C)PrinciplesofImaging(PROS-D)esofActiveSurveillanceandObservation(PROS-E)PrinciplesofRadiationTherapy(PROS-F)PrinciplesofSurgery(PROS-G)sofAndrogenDeprivationTherapyPROSHPrinciplesofNonHormonalSystemicTherapy(PROS-I)ClinicalTrials:NCCNbelievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.NCCNCategoriesofEvidenceandConsensus:Allrecommendationsarecategory2Aunlessotherwiseindicated.SeeNCCNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatment.AnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualclinicaltancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanyway.TheNCCNbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.©2022.Version3.2022,01/10/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.•FirstbulletremovedunderActiveSurveillance:Consider(PROS-E).PROS-4–Prednisone5mgorallyoncedailyforthestandardformulation.•FirstbulletremovedunderActiveSurveillance:Consider(PROS-E).PROS-4–Prednisone5mgorallyoncedailyforthestandardformulation.le◊FirstbulletremovedunderActiveSurveillance:Consider•ADTforM0PSAPersistence/RecurrenceAfterRPorEBRT(ADTforM0afterprogressiononsalvageEBRTContinuedUPDATESactivesurveillancealsoappliestoPROSEBRTPSARecurrence,TRUS-biopsynegativeorM0PSARecurrenceesurveillancepreferredformostpatientsPROSHof prostatebiopsy±mpMRI±prostatebiopsyand/ormolecularyearsoftheirdiagnosticbiopsy◊Abirateroneshouldbegivenwithconcurrentsteroid:dexsionoftheNCCNGuidelinesforProstateCancerfromVersioninclude•TheDiscussionsectionhasbeenupdatedtoreflectthechangesinthealgorithm.UpdatesinVersion2.2022oftheNCCNGuidelinesforProstateCancerfromVersion1.2022include:Version3.2022,01/10/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:42:44AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexsionoftheNCCNGuidelinesforProstateCancerfromVersionincludeGeneral:Terminologiesmodifiedtobemoreinclusiveofallsexualandgenderidentities.PROS-1•InitialProstateCancerDiagnosisandWorkup:Thispagewasextensivelyrevised.PROS-2•InitialRiskStratificationandStagingWorkupforClinicallyLocalizedDisease-Thispagewasextensivelyrevised.Columnsforgermlinetestingandmolecularbiomarkeranalysisoftumorwereremovedfromthispageandincludedinanewprinciplespage.•Thirdcolumnheadermodified:ImagingAdditionalEvaluation•Verylowriskgroup:pFirstbulletrevised:cT1cpBulletrevisedunderAdditionalEvaluation:Considerconfirmatoryprostatebiopsy±mpMRIifnotperformedpriortobiopsytoestablishcandidacyforactivesurveillance(AlsoforLowriskgroup)•Lowriskgroup:pFirstbulletmodified:cT1–cT2a•Intermediateriskgroup:pAdded(eg,<6of12cores)pFavorable,removedthefollowingbulletsfromAdditionalEvaluationcolumn:◊Boneimaging:notrecommendedforstaging◊Pelvic±abdominalimaging:recommendedifnomogrampredicts>10%probabilityofpelviclymphnodeinvolvement◊Ifregionalordistantmetastasesarefound,seePROS-8pModified:Considerconfirmatoryprostatebiopsy±mpMRIifnotperformedpriortobiopsytoestablishcandidacyforthoseconsideringactivesurveillancepUnfavorable,addedthefollowingbullettoAdditionalEvaluationcolumn:Boneandsofttissueimaging(AlsoforHighandVeryHighriskgroups)•Highriskgroup:pFirstbulletmodified:cT3aOR•Veryhighriskgroup:pFirstbulletmodified:cT3b–cT4•Footnotefmodified:Anultrasound-orMRI-orDRE-targetedlesionthatisbiopsiedmorethanonceanddemonstratescancer(regardlessofpercentagecoreinvolvementornumberofcoresinvolved)countscanbeconsideredasasinglepositivecore.•Footnotegremoved:Plainfilms,CT,MRI,orPET/CTorPET/MRIwithF-18sodiumfluoridePET/CTorPET/MRI,C-11cholinePET/CTorPET/MRI,orF-18fluciclovinePET/CTorPET/MRIcanbeconsideredforequivocalresultsoninitialboneimagingscan.SeePROS-D.•Replacedfootnotedwith:Tumor-basedmolecularassaysandgermlinegenetictestingareothertoolsthatcanassistwithriskstratification.SeePrinciplesofGeneticsandMolecular/BiomarkerAnalysis(PROS-B)todetermineifapatientisanappropriatecandidateforgermlinegenetictesting,andseePrinciplesofRiskStratification(PROS-C)todetermineifapatientisanappropriatecandidatefortumor-basedmolecularassays.•Footnoteiremoved:mpMRIispreferredoverCTforpelvic±abdominalabdominal/pelvicstaging.SeePROS-D.•Addedfootnotei:Boneimagingcanbeachievedbyconventionaltechnetium-99m-MDPbonescan.Plainfilms,CT,MRI,orPET/CTorPET/MRIwithF-18sodiumfluoride,C-11choline,F-18fluciclovine,Ga-68PSMA-11,orF-18piflufolastatPSMAcanbeconsideredforequivocalresultsoninitialboneimaging.Softtissueimagingofpelvis,abdomen,andchestcanincludechestCTandabdominal/pelvicCTorabdominal/pelvicMRI.mpMRIispreferredoverCTforpelvicstaging.Alternatively,Ga-68PSMA-11orF-18piflufolastatPSMAPET/CTorPET/MRIcanbeconsideredforboneandsofttissue(fullbody)imaging.SeePrinciplesofImaging(PROS-D).(AlsoforPROS-10,PROS-11A)•Addedfootnotej:BecauseoftheincreasedsensitivityandspecificityofPSMA-PETtracersfordetectingmicrometastaticdiseasecomparedtoconventionalimaging(CT,MRI)atbothinitialstagingandbiochemicalrecurrence,thePaneldoesnotfeelthatconventionalimagingisanecessaryprerequisitetoPSMA-PETandthatPSMA-PET/CTorPSMA-PET/MRIcanserveasanequallyeffective,ifnotmoreeffectivefront-lineimagingtoolforthesepatients.(AlsoforPROS-9,-10,-11A,-12,-13)Version3.2022,01/10/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESPrintedbyMinTangon3/14/20227:42:44AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexsionoftheNCCNGuidelinesforProstateCancerfromVersionincludePROS-3,PROS-4,PROS-5,PROS-6,PROS-7•ChangedObservationtoMonitoring,withconsiderationofearlyRTforadetectableandrisingPSAorPSA>0.1ng/mL.PROS-4•Removed:Activesurveillance(preferred)PROS-5•ChangedConsidermpMRIand/orprostatebiopsytoconfirmcandidacyforactivesurveillancetoConsiderconfirmatoryprostatebiopsywithorwithoutmpMRIandwithorwithoutmoleculartumoranalysistoestablishcandidacyforactivesurveillance.•Modified:EBRTorbrachytherapyalonePROS-6•Modified:Observation(preferred)PROS-7•Initialtherapy,changedformatandaddedabirateroneoption:pEBRT+ADT(1.5–3y;category1)orpEBRT+ADT(2y)+docetaxelfor6cycles(forvery-high-riskonly)orpEBRT+brachytherapy+ADT(1–3y;category1forADT)orpEBRT+ADT(2y)+abiraterone(forvery-high-riskonly)PROS-8•Previouspage,RegionalandMetastaticRiskGroup,wasremoved.•Regionalriskgroup,added(AnyT,N1,M0)totheheading.•Added:RP+PLNDwithadjuvanttherapyPROS-8A•Addedfootnote:Thefine-particleformulationofabirateronecanbeusedinsteadofthestandardform(category2B;otherrecommendedoption).•Revisedfootnotev:AddedafootnotelinkingtonewPrinciplesofRiskStratificationpage.•Footnotez:replacedsalvagetherapywithlocaltherapy.•Revisedfootnote:PatientswithpN1diseasewhochoseobservationshouldseePROS-10formonitoringforinitialdefinitivetherapyifPSAisundetectable.ForpatientswithpN1diseaseandPSApersistence,seePROS-10.•Modifiedfootnoteii:DocumentcastratelevelsoftestosteroneifonADTclinicallyindicated.Workupforprogressionshouldincludeboneandsofttissueevaluation.Boneimagingcanbeachievedbyconventionaltechnetium-99m-MDPbonescan.Plainfilms,CT,MRI,orPET/CTorPET/MRIwithF-18sodiumfluoride,C-11choline,F-18fluciclovine,Ga-68PSMA-11,orF-18piflufolastatPSMAcanbeconsideredforequivocalresultsoninitialboneimaging.Softtissueimagingofpelvis,abdomen,andchestcanincludechestCTandabdominal/pelvicCTorabdominal/pelvicMRI.Alternatively,Ga-68PSMA-11orF-18piflufolastatPSMAPET/CTorPET/MRIcanbeconsideredforboneandsofttissue(fullbody)imaging.SeePrinciplesofImaging(PROS-D).boneimaging,chestCT,andabdominal/pelvicCTwithcontrastorabdominal/pelvicMRIwithandwithoutcontrast.Ifthereisnoevidenceofmetastases,considerC-11cholinePET/CTorPET/MRIorF-18fluciclovinePET/CTorPET/MRIforfurthersofttissueandboneevaluationorF-18sodiumfluoridePET/CTorPET/MRIforfurtherboneevaluation.ThePanelremainsunsureofwhattodowhenM1issuggestedbythesePETtracersbutnotonconventionalimaging.(alsoonPROS-10throughPROS-13)•Removedfootnote:Theterm"castration-naïve"isusedtodefinepatientswhoarenotonADTatthetimeofprogression.TheNCCNProstateCancerPanelusestheterm"castration-naïve"evenwhenpatientshavehadneoadjuvant,concurrent,oradjuvantADTaspartofradiation.Version3.2022,01/10/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESPrintedbyMinTangon3/14/20227:42:44AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexsionoftheNCCNGuidelinesforProstateCancerfromVersioninclude•RadicalProstatectomyPSAPersistence/RecurrencepAdded:BoneandsofttissueimagingpRemovedthefollowingbullets:◊Boneimaging,◊ChestCT◊Abdominal/pelvicCTorabdominal/pelvicMRI◊C-11cholineorF-18fluciclovinePET/CTorPET/MRI•Removedfootnote:F-18sodiumfluorideorC-11cholineorF-18fluciclovinePET/CTorPET/MRIcanbeconsideredafterbonescanforfurtherevaluationwhenclinicalsuspicionofbonemetastasesishigh.•Removedfootnote:Histologicconfirmationisrecommendedwheneverfeasibleduetosignificantratesoffalsepositivity.PROS-11•RadiationTherapyRecurrencepRevised:PSApersistence/recurrenceorPositiveDREpRemovedthefollowingbullets:◊BoneImaging◊ProstateMRIpRevised:BoneandchestCTsofttissueimagingpRemovedthefollowingbullets:◊Abdominal/pelvicimagingCTorabdominal/pelvicMRI◊C-11cholineorF-18fluciclovinePET/CTorPET/MRIPROS-12•SystemicTherapyforCastration-NaiveProstateCancer:pRevised:MonitoringObservation(preferred)pRevised:ConsiderperiodicimagingforpatientswithM1tomonitortreatmentresponse•Footnoteadded:PSADTandGradeGroupshouldbeconsideredwhendecidingwhethertobeginADTforpatientswithM0disease.•Footnoteadded:Patientswithlifeexpectancy≤5yearscanconsiderobservation.SeePrinciplesofActiveSurveillanceandObservation(PROS-E).•Footnotemodified:Theterm"castration-naïve"isusedtodefinepatientswhohavenotbeentreatedwithADTandthosewhoarenotonADTatthetimeofprogression.•SystemicTherapyforM0Castration-ResistantProstateCancer:pRevised:ConventionalCRPC,imagingstudiesnegativefordistantmetastases(AlsoonPROS-14)pRevised:Considerperiodicdiseaseassessment(PSAandimaging)PSAincreasingpRevised:YesPSAincreasingorradiographicevidenceofmetastasespRevised:NoStablePSAandnoevidenceofmetastasespRevised:Maintaincurrenttreatmentandcontinuemonitoringconsiderperiodicdiseaseassessment(PSAandimaging)PROS-14•SystemicTherapyforM1CRPCpRevisedsecondbullet:TumortestingforMSI-HordMMRandforhomologousrecombinationgenemutations(HRRm),ifnotpreviouslyperformed.pRemovedbullet:Germlineandtumortestingforhomologousrecombinationgenemutationsifnotpreviouslyperformed.pAddedbullet:Considertumormutationalburden(TMB)testingpFirst-lineandsubsequenttreatmentoptions:pAdded:Cabazitaxel/carboplatin•Footnoteadded:GermlinetestingforHRRmisrecommendedifnotperformedpreviously.SeePrinciplesofGeneticsandMolecular/BiomarkerAnalysis(PROS-B).PROS-15•SystemicTherapyforM1CRPC:AdenocarcinomapPriornovelhormonetherapy/Nopriordocetaxel:◊Secondbullet,thirdsub-bulletrevised:PembrolizumabforMSI-H,dMMR,orTMB≥10mut/MbpPriordocetaxel/nopriornovelhormonetherapy:◊Secondbullet,thirdsub-bulletrevised:PembrolizumabforMSI-H,dMMR,orTMB≥10mut/MbpPriordocetaxelandpriornovelhormonetherapy:◊Secondbullet,thirdsub-bulletrevised:PembrolizumabforMSI-H,dMMR,orTMB≥10mut/MbVersion3.2022,01/10/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESPrintedbyMinTangon3/14/20227:42:44AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexsionoftheNCCNGuidelinesforProstateCancerfromVersioninclude•Footnoteremoved:Patientswithdiseaseprogressiononagiventherapyshouldnotrepeatthattherapy,withtheexceptionofdocetaxel,whichcanbegivenasarechallengeafterprogressiononanovelhormonetherapyinthemetastaticCRPCsettinginmenwhohavenotdemonstrateddefinitiveevidenceofprogressiononpriordocetaxeltherapyinthecastration-naïvesetting.PROS-A•PrinciplesofLifeExpectancyEstimationpFourthbulletmodified:Ifusingalifeexpectancytable,lifeexpectancycanshouldthenbeadjustedusingtheclinician’sassessmentofoverallhealthasfollowspFifthbulletmodified:Examplesofupper,middle,andlowerquartilesoflifeexpectancyatselectedagesareincluded5-yearincrementsofagearereproducedintheNCCNGuidelinesforOlderAdultOncologyforlifeexpectancyestimation.PROS-B•PrinciplesofGeneticsandMolecular/BiomarkerAnalysis:Thissectionhasbeenextensivelyrevised.PROS-C•PrinciplesofRiskStratification:Thissectionisnew.PROS-D(1of3)•BoneImaging:pSecond,third,andfourthbulletsmodified:BonescanimagingPROS-D(2of3)•BoneImaging(continued)pThirdbulletmodified:Bonescansandsofttissueimaging(CTorMRI)inpatientswithmetastaticprostatecancerornon-metastaticprogressiveprostatecancermaybeobtainedregularlyduringsystemictherapytoassessclinicalbenefit.pFifthbulletrevised:PETimaging/CTfordeletionofbonemetastaticdiseaseinpatientswithM0CRPC.pFifthbullet,secondsub-bulletrevised:Plainfilms,CT,MRI,PET/CTorPET/MRIwithF-18piflufolastatPSMA,Ga-68PSMA-11,F-18sodiumfluoride,C-11choline,orF-18fluciclovinecanbeconsideredforequivocalresultsoninitialbonescan.pFifthbullet,thirdsub-bulletadded:Ga-68PSMA-11orF-18piflufolastatPSMAPET/CTorPET/MRI(fullbodyimaging)canbeconsideredasanalternativetobonescan.pDeleted:F-18sodiumfluoridePET/CTorPET/MRImaybeusedtodetectbonemetastaticdiseasewithgreatersensitivitybutlessspecificitythanstandardbonescanimaging.PROS-D(3of3)•PositronEmissionTomography(PET)pBulletswerereorderedandrevised.pFirstbulletadded:PSMA-PETreferstoagrowingbodyofradiopharmaceuticalsthattargetPSMAonthesurfaceofprostatecells.TherearemultiplePSMAradiopharmaceuticalsatvariousstagesofinvestigation.Atthistime,theNCCNGuidelinesonlyrecommendthecurrentlyFDA-approvedPSMAagents,F-18piflufolastat(DCFPyL)andGa-68PSMA-11.SeeTable2intheDiscussionsectionformoredetail.pSecondbulletadded:F-18piflufolastatPSMAorGa-68PSMA-11PET/CTorPET/MRIcanbeconsideredasanalternativetostandardimagingofboneandsofttissueforinitialstaging,thedetectionofbiochemicallyrecurrentdisease,andasworkupforprogressionwithbonescanplusCTorMRIfortheevaluationofbone,pelvis,andabdomen.pFourthbulletadded:StudiessuggestthatF-18piflufolastatPSMAorGa-68PSMA-11PETimaginghaveahighersensitivitythanC-11cholineorF-18fluciclovinePETimaging,especiallyatverylowPSAlevels.pFifthbulletadded:BecauseoftheincreasedsensitivityandspecificityofPSMA-PETtracersfordetectingmicrometastaticdiseasecomparedtoconventionalimaging(CT,MRI)atbothinitialstagingandbiochemicalrecurrence,thePaneldoesnotfeelthatconventionalimagingisanecessaryprerequisitetoPSMA-PETandthatPSMA-PET/CTorPSMA-PET/MRIcanserveasanequallyeffective,ifnotmoreeffectivefront-lineimagingtoolforthesepatients.Version3.2022,01/10/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESPrintedbyMinTangon3/14/20227:42:44AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexsionoftheNCCNGuidelinesforProstateCancerfromVersionincludepSixthbulletadded:HistologicorradiographicconfirmationpSixthbulletadded:HistologicorradiographicconfirmationofinvolvementdetectedbyPETimagingisrecommendedwheneverfeasibleduetothepresenceoffalsepositives.Althoughfalsepositivesexist,literaturesuggeststhattheseareoutweighedbytheincreaseintruepositivesdetectedbyPETrelativetoconventionalimaging.Toreducethefalse-positiverate,physiciansshouldconsidertheintensityofPSMA-PETuptakeandcorrelativeCTfindingsintheinterpretationofscans.Severalreportingsystemshavebeenproposedbutwillnothavebeenvalidatedorwidelyused.pBulletremoved:TheuseofPET/CTorPET/MRIimagingusingtracersotherthanF-18FDGforstagingofsmall-volumerecurrentormetastaticprostatecancerisarapidlydevelopingfieldwhereinmostofthedataarederivedfromsingle-institutionseriesorregistrystudies.FDAclearanceandreimbursementfor