PSMA PET finds nodal and bone disease earlier than CT and bone scan, at staging of high-risk disease and at biochemical recurrence; report with PROMISE / E-PSMA (miTNM) and know the physiological uptake and the non-prostate PSMA-avid lesions that mimic metastases.
Orient first
- Physiological uptake: salivary and lacrimal glands, liver, spleen, kidneys, bowel, bladder (ureters mimic nodes).
- Pitfalls: coeliac and stellate ganglia, rib fractures, Paget disease, fibrous dysplasia, haemangiomas, other tumours (renal, HCC, glioma) express PSMA.
- PROMISE / E-PSMA reporting (miTNM, expression score) standardises the report (verify version).
Acquire the study
- 68Ga-PSMA-11 or 18F-PSMA PET-CT from vertex to mid-thigh ~60 min after injection; diuretic and a late pelvic acquisition help separate bladder and nodes.
The manoeuvre
- Prostate bed or gland: focal uptake; SUVmax.
- Pelvic nodes (internal/external iliac, obturator, presacral) on the fused axial series — PSMA expression vs liver/spleen/parotid.
- Extrapelvic nodes (retroperitoneal, supradiaphragmatic).
- Bone: focal uptake with or without CT correlate; distinguish rib fracture (linear, healing).
- Visceral: lung, liver.
- miTNM stage and PSMA expression score per lesion.
What confirms it
- PSMA-avid lesions with typical distribution and CT correlate, reported with miTNM.
What licenses you to exclude it
- A negative PSMA PET at very low PSA does not exclude recurrence (detection depends on PSA — verify).
The classic misread
- Calling ganglia or a ureter a nodal metastasis.