Figure 2. Imaging Algorithm for Patients with Rising Prostate-
Specific Antigen (PSA) After Local Treatment
Rising PSA after local
treatment
Conventional imaging
negative for mets
Local therapy
not planned or
inappropriate
Suitable for salvage
local therapy
No indication
for NGI
Previous radical
prostatectomy
Previous
radiotherapy or
ablation (whole
gland or focal)
Consider NGI where
available
a
(WB-MRI,
11
C-choline PET,
18
F-fluciclovine PET,
18
F-NaF
PET, or PSMA PET
b
)
Consider NGI where
available
a
(WB-MRI,
11
C-choline PET,
18
F-fluciclovine PET,
18
F-NaF
PET, or PSMA PET
b
)
NGI positive:
Consider biopsy of
accessible lesions
NGI negative NGI positive
Consider mpMRI
prostate ±
prostate biopsy
Prostate only
Outside of
prostate:
Consider biopsy
of accessible
lesions
Consider mpMRI
prostate ±
prostate biopsy
a
For men for whom salvage local therapy (e.g.
salvage radiation, salvage prostatectomy) is an
option, there is evidence supporting the use of
NGI to assess local or distant sites of disease,
which may guide therapy away from salvage
local therapy if indicative of distant metastatic
disease.
b
ere is enthusiasm for the potential added
value of PSMA PET/CT and PET/MRI for
the assessment of the local and metastatic extent
of prostate cancer in this context, although
PSMA imaging is not currently FDA approved
and should thus be only performed as part of a
clinical trial or other controlled research setting.
