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Pretreatment Detection, Surveillance, and Staging of Prostate Cancer

Variant: 1   Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI-targeted biopsy prostate Usually Appropriate O
TRUS-guided biopsy prostate Usually Appropriate O
MRI pelvis without and with IV contrast Usually Appropriate O
MRI pelvis without IV contrast Usually Appropriate O
TRUS prostate Usually Not Appropriate O
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
MRI whole body without and with IV contrast Usually Not Appropriate O
MRI whole body without IV contrast Usually Not Appropriate O
Bone scan whole body Usually Not Appropriate ☢☢☢
Choline PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢
Choline PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
Fluciclovine PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
FDG-PET/CT whole body Usually Not Appropriate ☢☢☢☢
Fluciclovine PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢
Fluoride PET/CT whole body Usually Not Appropriate ☢☢☢☢
PSMA PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 2   Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
MRI-targeted biopsy prostate Usually Appropriate O
TRUS-guided biopsy prostate Usually Appropriate O
MRI pelvis without and with IV contrast Usually Appropriate O
MRI pelvis without IV contrast Usually Appropriate O
TRUS prostate Usually Not Appropriate O
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
MRI whole body without and with IV contrast Usually Not Appropriate O
MRI whole body without IV contrast Usually Not Appropriate O
Bone scan whole body Usually Not Appropriate ☢☢☢
Choline PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢
Choline PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
Fluciclovine PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
FDG-PET/CT whole body Usually Not Appropriate ☢☢☢☢
Fluciclovine PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢
Fluoride PET/CT whole body Usually Not Appropriate ☢☢☢☢
PSMA PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 3   Clinically established low-risk prostate cancer. Active surveillance.
Procedure Appropriateness Category Relative Radiation Level
MRI-targeted biopsy prostate Usually Appropriate O
TRUS-guided biopsy prostate Usually Appropriate O
MRI pelvis without and with IV contrast Usually Appropriate O
MRI pelvis without IV contrast Usually Appropriate O
TRUS prostate Usually Not Appropriate O
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
MRI whole body without and with IV contrast Usually Not Appropriate O
MRI whole body without IV contrast Usually Not Appropriate O
Bone scan whole body Usually Not Appropriate ☢☢☢
Choline PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢
Choline PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
Fluciclovine PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT chest abdomen pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
FDG-PET/CT whole body Usually Not Appropriate ☢☢☢☢
Fluciclovine PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢
Fluoride PET/CT whole body Usually Not Appropriate ☢☢☢☢
PSMA PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 4   Clinically established intermediate-risk prostate cancer. Staging or surveillance.
Procedure Appropriateness Category Relative Radiation Level
MRI-targeted biopsy prostate Usually Appropriate O
MRI abdomen and pelvis without and with IV contrast Usually Appropriate O
MRI pelvis without and with IV contrast Usually Appropriate O
CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢
CT chest abdomen pelvis with IV contrast Usually Appropriate ☢☢☢☢
Fluciclovine PET/CT skull base to mid-thigh Usually Appropriate ☢☢☢☢
PSMA PET/CT skull base to mid-thigh Usually Appropriate ☢☢☢☢
TRUS-guided biopsy prostate May Be Appropriate O
MRI abdomen and pelvis without IV contrast May Be Appropriate O
MRI pelvis without IV contrast May Be Appropriate O
MRI whole body without and with IV contrast May Be Appropriate (Disagreement) O
MRI whole body without IV contrast May Be Appropriate (Disagreement) O
Bone scan whole body May Be Appropriate ☢☢☢
Choline PET/CT skull base to mid-thigh May Be Appropriate ☢☢☢
Choline PET/MRI skull base to mid-thigh May Be Appropriate ☢☢☢
CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢
Fluciclovine PET/MRI skull base to mid-thigh May Be Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
CT chest abdomen pelvis without IV contrast May Be Appropriate ☢☢☢☢
Fluoride PET/CT whole body May Be Appropriate ☢☢☢☢
TRUS prostate Usually Not Appropriate O
FDG-PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
CT chest abdomen pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
FDG-PET/CT whole body Usually Not Appropriate ☢☢☢☢

Variant: 5   Clinically established high-risk prostate cancer. Staging.
Procedure Appropriateness Category Relative Radiation Level
MRI abdomen and pelvis without and with IV contrast Usually Appropriate O
MRI pelvis without and with IV contrast Usually Appropriate O
Bone scan whole body Usually Appropriate ☢☢☢
Choline PET/CT skull base to mid-thigh Usually Appropriate ☢☢☢
Choline PET/MRI skull base to mid-thigh Usually Appropriate ☢☢☢
CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢
Fluciclovine PET/MRI skull base to mid-thigh Usually Appropriate ☢☢☢
CT chest abdomen pelvis with IV contrast Usually Appropriate ☢☢☢☢
Fluciclovine PET/CT skull base to mid-thigh Usually Appropriate ☢☢☢☢
Fluoride PET/CT whole body Usually Appropriate ☢☢☢☢
PSMA PET/CT skull base to mid-thigh Usually Appropriate ☢☢☢☢
MRI abdomen and pelvis without IV contrast May Be Appropriate O
MRI pelvis without IV contrast May Be Appropriate O
MRI whole body without and with IV contrast May Be Appropriate O
MRI whole body without IV contrast May Be Appropriate O
CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
CT chest abdomen pelvis without IV contrast May Be Appropriate ☢☢☢☢
MRI-targeted biopsy prostate Usually Not Appropriate O
TRUS prostate Usually Not Appropriate O
TRUS-guided biopsy prostate Usually Not Appropriate O
FDG-PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
CT chest abdomen pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
FDG-PET/CT whole body Usually Not Appropriate ☢☢☢☢

Panel Members
Oguz Akin, MDa; Sungmin Woo, MD, PhDb; Aytekin Oto, MDc; Brian C. Allen, MDd; Ryan Avery, MDe; Samantha J. Barker, MDf; Marielia Gerena, MDg; David J. Halpern, MD, MPHh; Lori Mankowski Gettle, MD, MBAi; Seth A. Rosenthal, MDj; Samir S.. Taneja, MDk; Baris Turkbey, MDl; Pat Whitworth III, MDm; Paul Nikolaidis, MDn.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
A. Bone Scan Whole Body
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
B. Choline PET/CT Skull Base to Mid-Thigh
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
C. Choline PET/MRI Skull Base to Mid-Thigh
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
D. CT Abdomen and Pelvis With IV Contrast 
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
E. CT Abdomen and Pelvis Without and With IV Contrast
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
F. CT Abdomen and Pelvis Without IV Contrast
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
G. CT Chest, Abdomen, and Pelvis With IV Contrast
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
H. CT Chest, Abdomen, and Pelvis Without and With IV Contrast
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
I. CT Chest, Abdomen, and Pelvis Without IV Contrast
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
J. FDG-PET/CT Whole Body
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
K. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
L. Fluciclovine PET/CT Skull Base to Mid-Thigh
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
M. Fluciclovine PET/MRI Skull Base to Mid-Thigh
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
N. Fluoride PET/CT Whole Body
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
O. MRI Abdomen and Pelvis Without and With IV Contrast
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
P. MRI Abdomen and Pelvis Without IV Contrast
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
Q. MRI Pelvis Without and With IV Contrast
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
R. MRI Pelvis Without IV Contrast
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
S. MRI-Targeted Biopsy Prostate
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
T. MRI Whole Body Without and With IV Contrast
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
U. MRI Whole Body Without IV Contrast
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
V. PSMA PET/CT Skull Base to Mid-Thigh
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
W. TRUS Prostate
Variant 1: Clinically suspected prostate cancer. No prior biopsy (biopsy naïve). Initial diagnosis. Initial imaging.
X. TRUS-Guided Biopsy Prostate
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
A. Bone Scan Whole Body
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
B. Choline PET/CT Skull Base to Mid-Thigh
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
C. Choline PET/MRI Skull Base to Mid-Thigh
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
D. CT Abdomen and Pelvis With IV Contrast
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
E. CT Abdomen and Pelvis Without and With IV Contrast
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
F. CT Abdomen and Pelvis Without IV Contrast
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
G. CT Chest, Abdomen, and Pelvis With IV Contrast
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
H. CT Chest, Abdomen, and Pelvis Without and With IV Contrast
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
I. CT Chest, Abdomen, and Pelvis Without IV Contrast
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
J. FDG-PET/CT Whole Body
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
K. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
L. Fluciclovine PET/CT Skull Base to Mid-Thigh
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
M. Fluciclovine PET/MRI Skull Base to Mid-Thigh
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
N. Fluoride PET/CT Whole Body
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
O. MRI Abdomen and Pelvis Without and With IV Contrast
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
P. MRI Abdomen and Pelvis Without IV Contrast
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
Q. MRI Pelvis Without and With IV Contrast
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
R. MRI Pelvis Without IV Contrast
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
S. MRI-Targeted Biopsy Prostate
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
T. MRI Whole Body Without and With IV Contrast
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
U. MRI Whole Body Without IV Contrast
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
V. PSMA PET/CT Skull Base to Mid-Thigh
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
W. TRUS Prostate
Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study.
X. TRUS-Guided Biopsy Prostate
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
A. Bone Scan Whole Body
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
B. Choline PET/CT Skull Base to Mid-Thigh
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
C. Choline PET/MRI Skull Base to Mid-Thigh
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
D. CT Abdomen and Pelvis With IV Contrast
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
E. CT Abdomen and Pelvis Without and With IV Contrast
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
F. CT Abdomen and Pelvis Without IV contrast
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
G. CT Chest, Abdomen, and Pelvis With IV Contrast
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
H. CT Chest, Abdomen, and Pelvis Without and With IV Contrast
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
I. CT Chest, Abdomen, and Pelvis Without IV Contrast
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
J. FDG-PET/CT Whole Body
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
K. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
L. Fluciclovine PET/CT Skull Base to Mid-Thigh
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
M. Fluciclovine PET/MRI Skull Base to Mid-Thigh 
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
N. Fluoride PET/CT Whole Body
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
O. MRI Abdomen and Pelvis Without and With IV Contrast
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
P. MRI Abdomen and Pelvis Without IV Contrast
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
Q. MRI Pelvis Without and With IV Contrast
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
R. MRI Pelvis Without IV Contrast
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
S. MRI-Targeted Biopsy Prostate
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
T. MRI Whole Body Without and With IV Contrast
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
U. MRI Whole Body Without IV Contrast
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
V. PSMA PET/CT Skull Base to Mid-Thigh
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
W. TRUS Prostate
Variant 3: Clinically established low-risk prostate cancer. Active surveillance.
X. TRUS-Guided Biopsy Prostate
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
A. Bone Scan Whole Body
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
B. Choline PET/CT Skull Base to Mid-Thigh
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
C. Choline PET/MRI Skull Base to Mid-Thigh
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
D. CT Abdomen and Pelvis With IV Contrast
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
E. CT Abdomen and Pelvis Without and With IV Contrast
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
F. CT Abdomen and Pelvis Without IV Contrast
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
G. CT Chest, Abdomen, and Pelvis With IV Contrast
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
H. CT Chest, Abdomen, and Pelvis Without and With IV Contrast
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
I. CT Chest, Abdomen, and Pelvis Without IV Contrast
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
J. FDG-PET/CT Whole Body
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
K. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
L. Fluciclovine PET/CT Skull Base to Mid-Thigh
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
M. Fluciclovine PET/MRI Skull Base to Mid-Thigh
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
N. Fluoride PET/CT Whole Body
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
O. MRI Abdomen and Pelvis Without and With IV Contrast
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
P. MRI Abdomen and Pelvis Without IV Contrast
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
Q. MRI Pelvis Without and With IV Contrast
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
R. MRI Pelvis Without IV Contrast
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
S. MRI-Targeted Biopsy Prostate
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
T. MRI Whole Body Without and With IV Contrast
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
U. MRI Whole Body Without IV Contrast
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
V. PSMA PET/CT Skull Base to Mid-Thigh
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
W. TRUS Prostate
Variant 4: Clinically established intermediate-risk prostate cancer. Staging or surveillance.
X. TRUS-Guided Biopsy Prostate
Variant 5: Clinically established high-risk prostate cancer. Staging.
Variant 5: Clinically established high-risk prostate cancer. Staging.
A. Bone Scan Whole Body
Variant 5: Clinically established high-risk prostate cancer. Staging.
B. Choline PET/CT Skull Base to Mid-Thigh
Variant 5: Clinically established high-risk prostate cancer. Staging.
C. Choline PET/MRI Skull Base to Mid-Thigh 
Variant 5: Clinically established high-risk prostate cancer. Staging.
D. CT Abdomen and Pelvis With IV Contrast
Variant 5: Clinically established high-risk prostate cancer. Staging.
E. CT Abdomen and Pelvis Without and With IV Contrast
Variant 5: Clinically established high-risk prostate cancer. Staging.
F. CT Abdomen and Pelvis Without IV Contrast
Variant 5: Clinically established high-risk prostate cancer. Staging.
G. CT Chest, Abdomen, and Pelvis With IV Contrast
Variant 5: Clinically established high-risk prostate cancer. Staging.
H. CT Chest, Abdomen, and Pelvis Without and With IV Contrast
Variant 5: Clinically established high-risk prostate cancer. Staging.
I. CT Chest, Abdomen, and Pelvis Without IV Contrast
Variant 5: Clinically established high-risk prostate cancer. Staging.
J. FDG-PET/CT Whole Body
Variant 5: Clinically established high-risk prostate cancer. Staging.
K. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 5: Clinically established high-risk prostate cancer. Staging.
L. Fluciclovine PET/CT Skull Base to Mid-Thigh
Variant 5: Clinically established high-risk prostate cancer. Staging.
M. Fluciclovine PET/MRI Skull Base to Mid-Thigh
Variant 5: Clinically established high-risk prostate cancer. Staging.
N. Fluoride PET/CT Whole Body
Variant 5: Clinically established high-risk prostate cancer. Staging.
O. MRI Abdomen and Pelvis Without and With IV Contrast
Variant 5: Clinically established high-risk prostate cancer. Staging.
P. MRI Abdomen and Pelvis Without IV Contrast
Variant 5: Clinically established high-risk prostate cancer. Staging.
Q. MRI Pelvis Without and With IV Contrast
Variant 5: Clinically established high-risk prostate cancer. Staging.
R. MRI Pelvis Without IV Contrast
Variant 5: Clinically established high-risk prostate cancer. Staging.
S. MRI-Targeted Biopsy Prostate
Variant 5: Clinically established high-risk prostate cancer. Staging.
T. MRI Whole Body Without and With IV Contrast
Variant 5: Clinically established high-risk prostate cancer. Staging.
U. MRI Whole Body Without IV Contrast
Variant 5: Clinically established high-risk prostate cancer. Staging.
V. PSMA PET/CT Skull Base to Mid-Thigh
Variant 5: Clinically established high-risk prostate cancer. Staging.
W. TRUS Prostate
Variant 5: Clinically established high-risk prostate cancer. Staging.
X. TRUS-Guided Biopsy Prostate
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
References
1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 70(1):7-30, 2020 01.
2. Roehrborn CG, Black LK. The economic burden of prostate cancer. BJU Int. 2011;108(6):806-813.
3. Evans AJ, Henry PC, Van der Kwast TH, et al. Interobserver variability between expert urologic pathologists for extraprostatic extension and surgical margin status in radical prostatectomy specimens. Am J Surg Pathol 2008;32:1503-12.
4. van der Kwast TH, Collette L, Van Poppel H, et al. Impact of pathology review of stage and margin status of radical prostatectomy specimens (EORTC trial 22911). Virchows Arch. 2006;449(4):428-434.
5. localization Graser A, Heuck A, Sommer B, et al. Per-sextant localization and staging of prostate cancer: correlation of imaging findings with whole-mount step section histopathology. AJR Am J Roentgenol 2007;188:84-90.
6. D'Amico AV, Whittington R, Malkowicz SB, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. Jama. 1998;280(11):969-974.
7. Eifler JB, Feng Z, Lin BM, et al. An updated prostate cancer staging nomogram (Partin tables) based on cases from 2006 to 2011. BJU Int. 2013;111(1):22-29.
8. Karakiewicz PI, Bhojani N, Capitanio U, et al. External validation of the updated Partin tables in a cohort of North American men. J Urol. 2008; 180(3):898-902; discussion 902-893.
9. Yu JB, Makarov DV, Sharma R, Peschel RE, Partin AW, Gross CP. Validation of the partin nomogram for prostate cancer in a national sample. J Urol. 2010; 183(1):105-111.
10. Rayn KN, Bloom JB, Gold SA, et al. Added Value of Multiparametric Magnetic Resonance Imaging to Clinical Nomograms for Predicting Adverse Pathology in Prostate Cancer. J Urol. 200(5):1041-1047, 2018 11.
11. Sandeman K, Eineluoto JT, Pohjonen J, et al. Prostate MRI added to CAPRA, MSKCC and Partin cancer nomograms significantly enhances the prediction of adverse findings and biochemical recurrence after radical prostatectomy. PLoS ONE. 15(7):e0235779, 2020.
12. Greene DJ, Elshafei A, Nyame YA, et al. External validation of a PCA-3-based nomogram for predicting prostate cancer and high-grade cancer on initial prostate biopsy. Prostate. 76(11):1019-23, 2016 08.
13. Punnen S, Nahar B, Soodana-Prakash N, et al. Optimizing patient's selection for prostate biopsy: A single institution experience with multi-parametric MRI and the 4Kscore test for the detection of aggressive prostate cancer. PLoS ONE. 13(8):e0201384, 2018.
14. Palsdottir T, Nordstrom T, Aly M, et al. A Unified Prostate Cancer Risk Prediction Model Combining the Stockholm3 Test and Magnetic Resonance Imaging. Eur Urol Oncol. 2(5):490-496, 2019 09.
15. Fenstermaker M, Mendhiratta N, Bjurlin MA, et al. Risk Stratification by Urinary Prostate Cancer Gene 3 Testing Before Magnetic Resonance Imaging-Ultrasound Fusion-targeted Prostate Biopsy Among Men With No History of Biopsy. Urology. 99:174-179, 2017 Jan.
16. Duffy MJ.. Biomarkers for prostate cancer: prostate-specific antigen and beyond. [Review]. Clin Chem Lab Med. 58(3):326-339, 2020 02 25.
17. Lamy PJ, Allory Y, Gauchez AS, et al. Prognostic Biomarkers Used for Localised Prostate Cancer Management: A Systematic Review. Eur Urol Focus. 4(6):790-803, 2018 12.
18. Bjurlin MA, Rosenkrantz AB, Beltran LS, Raad RA, Taneja SS. Imaging and evaluation of patients with high-risk prostate cancer. Nat Rev Urol. 2015;12(11):617-628.
19. Hicks RM, Simko JP, Westphalen AC, et al. Diagnostic Accuracy of 68Ga-PSMA-11 PET/MRI Compared with Multiparametric MRI in the Detection of Prostate Cancer. Radiology. 289(3):730-737, 2018 12.
20. Sandhu GS, Andriole GL. Overdiagnosis of prostate cancer. J Natl Cancer Inst Monogr. 2012;2012(45):146-151.
21. Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet. 2014;384(9959):2027-2035.
22. Hugosson J, Roobol MJ, Mansson M, et al. A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer. Eur Urol. 76(1):43-51, 2019 07.
23. Kasivisvanathan V, Rannikko AS, Borghi M, et al. MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis. N Engl J Med. 378(19):1767-1777, 2018 May 10.
24. van der Leest M, Cornel E, Israel B, et al. Head-to-head Comparison of Transrectal Ultrasound-guided Prostate Biopsy Versus Multiparametric Prostate Resonance Imaging with Subsequent Magnetic Resonance-guided Biopsy in Biopsy-naive Men with Elevated Prostate-specific Antigen: A Large Prospective Multicenter Clinical Study. Eur Urol. 75(4):570-578, 2019 04.
25. Rouviere O, Puech P, Renard-Penna R, et al. Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy-naive patients (MRI-FIRST): a prospective, multicentre, paired diagnostic study. Lancet Oncol. 20(1):100-109, 2019 01.
26. Ahdoot M, Wilbur AR, Reese SE, et al. MRI-Targeted, Systematic, and Combined Biopsy for Prostate Cancer Diagnosis. N Engl J Med. 382(10):917-928, 2020 03 05.
27. Ahmed HU, El-Shater Bosaily A, Brown LC, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet. 389(10071):815-822, 2017 02 25.
28. Drost FH, Osses DF, Nieboer D, et al. Prostate MRI, with or without MRI-targeted biopsy, and systematic biopsy for detecting prostate cancer. Cochrane Database Syst Rev. 4:CD012663, 2019 04 25.
29. Moore CM, Robertson NL, Arsanious N, et al. Image-guided prostate biopsy using magnetic resonance imaging-derived targets: a systematic review. Eur Urol 2013;63:125-40.
30. Woo S, Suh CH, Eastham JA, et al. Comparison of Magnetic Resonance Imaging-stratified Clinical Pathways and Systematic Transrectal Ultrasound-guided Biopsy Pathway for the Detection of Clinically Significant Prostate Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Eur Urol Oncol. 2(6):605-616, 2019 11.
31. Woo S, Suh CH, Kim SY, Cho JY, Kim SH. Shear-Wave Elastography for Detection of Prostate Cancer: A Systematic Review and Diagnostic Meta-Analysis. [Review]. AJR Am J Roentgenol. 209(4):806-814, 2017 Oct.
32. Boehm K, Tennstedt P, Beyer B, et al. Additional elastography-targeted biopsy improves the agreement between biopsy Gleason grade and Gleason grade at radical prostatectomy. World J Urol. 34(6):805-10, 2016 Jun.
33. Lughezzani G, Saita A, Lazzeri M, et al. Comparison of the Diagnostic Accuracy of Micro-ultrasound and Magnetic Resonance Imaging/Ultrasound Fusion Targeted Biopsies for the Diagnosis of Clinically Significant Prostate Cancer. Eur Urol Oncol. 2(3):329-332, 2019 05.
34. Mannaerts CK, Wildeboer RR, Remmers S, et al. Multiparametric Ultrasound for Prostate Cancer Detection and Localization: Correlation of B-mode, Shear Wave Elastography and Contrast Enhanced Ultrasound with Radical Prostatectomy Specimens. J Urol. 202(6):1166-1173, 2019 12.
35. Baur ADJ, Schwabe J, Rogasch J, et al. A direct comparison of contrast-enhanced ultrasound and dynamic contrast-enhanced magnetic resonance imaging for prostate cancer detection and prediction of aggressiveness. Eur Radiol. 28(5):1949-1960, 2018 May.
36. Trabulsi EJ, Calio BP, Kamel SI, et al. Prostate Contrast Enhanced Transrectal Ultrasound Evaluation of the Prostate With Whole-Mount Prostatectomy Correlation. Urology. 133:187-191, 2019 Nov.
37. Heesakkers RA, Hovels AM, Jager GJ, et al. MRI with a lymph-node-specific contrast agent as an alternative to CT scan and lymph-node dissection in patients with prostate cancer: a prospective multicohort study. Lancet Oncol. 9(9):850-6, 2008 Sep.
38. Birkhauser FD, Studer UE, Froehlich JM, et al. Combined ultrasmall superparamagnetic particles of iron oxide-enhanced and diffusion-weighted magnetic resonance imaging facilitates detection of metastases in normal-sized pelvic lymph nodes of patients with bladder and prostate cancer. Eur Urol. 64(6):953-60, 2013 Dec.
39. Woo S, Suh CH, Kim SY, Cho JY, Kim SH. Diagnostic Performance of Prostate Imaging Reporting and Data System Version 2 for Detection of Prostate Cancer: A Systematic Review and Diagnostic Meta-analysis. [Review]. Eur Urol. 72(2):177-188, 2017 08.
40. Mertan FV, Greer MD, Shih JH, et al. Prospective Evaluation of the Prostate Imaging Reporting and Data System Version 2 for Prostate Cancer Detection. J Urol. 196(3):690-6, 2016 Sep.
41. Purysko AS, Bittencourt LK, Bullen JA, Mostardeiro TR, Herts BR, Klein EA. Accuracy and Interobserver Agreement for Prostate Imaging Reporting and Data System, Version 2, for the Characterization of Lesions Identified on Multiparametric MRI of the Prostate. AJR Am J Roentgenol. 209(2):339-349, 2017 Aug.
42. Greer MD, Shih JH, Barrett T, et al. All over the map: An interobserver agreement study of tumor location based on the PI-RADSv2 sector map. J Magn Reson Imaging. 48(2):482-490, 2018 08.
43. Mussi TC, Yamauchi FI, Tridente CF, et al. Interobserver Agreement and Positivity of PI-RADS Version 2 Among Radiologists with Different Levels of Experience. Acad Radiol. 26(8):1017-1022, 2019 08.
44. Moldovan PC, Van den Broeck T, Sylvester R, et al. What Is the Negative Predictive Value of Multiparametric Magnetic Resonance Imaging in Excluding Prostate Cancer at Biopsy? A Systematic Review and Meta-analysis from the European Association of Urology Prostate Cancer Guidelines Panel. [Review]. Eur Urol. 72(2):250-266, 2017 08.
45. Hansen NL, Barrett T, Koo B, et al. The influence of prostate-specific antigen density on positive and negative predictive values of multiparametric magnetic resonance imaging to detect Gleason score 7-10 prostate cancer in a repeat biopsy setting. BJU Int. 119(5):724-730, 2017 05.
46. Rosenkrantz AB, Shanbhogue AK, Wang A, Kong MX, Babb JS, Taneja SS. Length of capsular contact for diagnosing extraprostatic extension on prostate MRI: Assessment at an optimal threshold. J Magn Reson Imaging. 43(4):990-7, 2016 Apr.
47. Woo S, Kim SY, Cho JY, Kim SH. Length of capsular contact on prostate MRI as a predictor of extracapsular extension: which is the most optimal sequence?. Acta Radiol. 58(4):489-497, 2017 Apr.
48. Mehralivand S, Shih JH, Harmon S, et al. A Grading System for the Assessment of Risk of Extraprostatic Extension of Prostate Cancer at Multiparametric MRI. Radiology. 290(3):709-719, 2019 03.
49. de Rooij M, Hamoen EH, Witjes JA, Barentsz JO, Rovers MM. Accuracy of Magnetic Resonance Imaging for Local Staging of Prostate Cancer: A Diagnostic Meta-analysis. Eur Urol. 2015:[E-pub ahead of print].
50. Verma S, Turkbey B, Muradyan N, et al. Overview of dynamic contrast-enhanced MRI in prostate cancer diagnosis and management. AJR Am J Roentgenol. 2012;198(6):1277-1288.
51. Weinreb JC, Barentsz JO, Choyke PL, et al. PI-RADS Prostate Imaging - Reporting and Data System: 2015, Version 2. Eur Urol. 69(1):16-40, 2016 Jan.
52. Romero G, Foster BR, Pettersson DR, Fung AW, Guimaraes AR, Coakley FV. Endorectal multiparametric MRI of the prostate: incremental effect of perfusion imaging on biopsy target identification. Clin Imaging. 40(3):553-7, 2016 May-Jun.
53. Hotker AM, Mazaheri Y, Aras O, et al. Assessment of Prostate Cancer Aggressiveness by Use of the Combination of Quantitative DWI and Dynamic Contrast-Enhanced MRI. AJR Am J Roentgenol. 206(4):756-63, 2016 Apr.
54. Woo S, Suh CH, Kim SY, Cho JY, Kim SH, Moon MH. Head-to-Head Comparison Between Biparametric and Multiparametric MRI for the Diagnosis of Prostate Cancer: A Systematic Review and Meta-Analysis. AJR Am J Roentgenol. 211(5):W226-W241, 2018 11.
55. Klein EA. Prostate cancer: MR-TRUS fusion biopsy--defining a new standard. Nat Rev Clin Oncol. 2015;12(5):253-254.
56. Wysock JS, Rosenkrantz AB, Huang WC, et al. A prospective, blinded comparison of magnetic resonance (MR) imaging-ultrasound fusion and visual estimation in the performance of MR-targeted prostate biopsy: the PROFUS trial. Eur Urol. 2014;66(2):343-351.
57. Wegelin O, Exterkate L, van der Leest M, et al. The FUTURE Trial: A Multicenter Randomised Controlled Trial on Target Biopsy Techniques Based on Magnetic Resonance Imaging in the Diagnosis of Prostate Cancer in Patients with Prior Negative Biopsies. Eur Urol. 75(4):582-590, 2019 04.
58. Hamid S, Donaldson IA, Hu Y, et al. The SmartTarget Biopsy Trial: A Prospective, Within-person Randomised, Blinded Trial Comparing the Accuracy of Visual-registration and Magnetic Resonance Imaging/Ultrasound Image-fusion Targeted Biopsies for Prostate Cancer Risk Stratification. Eur Urol. 75(5):733-740, 2019 05.
59. Porreca A, Del Giudice F, Giampaoli M, et al. Adding systematic biopsy to magnetic resonance ultrasound fusion targeted biopsy of the prostate in men with previous negative biopsy or enrolled in active surveillance programs: A prospective single center, randomized study. Medicine (Baltimore). 99(37):e22059, 2020 Sep 11.
60. Baco E, Rud E, Eri LM, et al. A Randomized Controlled Trial To Assess and Compare the Outcomes of Two-core Prostate Biopsy Guided by Fused Magnetic Resonance and Transrectal Ultrasound Images and Traditional 12-core Systematic Biopsy. Eur Urol. 69(1):149-56, 2016 Jan.
61. Porpiglia F, Manfredi M, Mele F, et al. Diagnostic Pathway with Multiparametric Magnetic Resonance Imaging Versus Standard Pathway: Results from a Randomized Prospective Study in Biopsy-naive Patients with Suspected Prostate Cancer. Eur Urol. 72(2):282-288, 2017 08.
62. Pessoa RR, Viana PC, Mattedi RL, et al. Value of 3-Tesla multiparametric magnetic resonance imaging and targeted biopsy for improved risk stratification in patients considered for active surveillance. BJU Int. 119(4):535-542, 2017 04.
63. Jambor I, Bostrom PJ, Taimen P, et al. Novel biparametric MRI and targeted biopsy improves risk stratification in men with a clinical suspicion of prostate cancer (IMPROD Trial). J Magn Reson Imaging. 46(4):1089-1095, 2017 10.
64. Muthigi A, Sidana A, George AK, et al. Midline lesions of the prostate: role of MRI/TRUS fusion biopsy and implications in Gleason risk stratification. Int Urol Nephrol. 48(9):1445-52, 2016 Sep.
65. Smeenge M, de la Rosette JJ, Wijkstra H. Current status of transrectal ultrasound techniques in prostate cancer. Curr Opin Urol. 2012;22(4):297-302.
66. Steinkohl F, Luger AK, Pichler R, et al. Visibility of MRI prostate lesions on B-mode transrectal ultrasound. Med. ultrasonography. 20(4):441-445, 2018 Dec 08.
67. Onur R, Littrup PJ, Pontes JE, Bianco FJ, Jr. Contemporary impact of transrectal ultrasound lesions for prostate cancer detection. J Urol. 2004;172(2):512-514.
68. Hodge KK, McNeal JE, Terris MK, Stamey TA. Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate. J Urol. 1989;142(1):71-74; discussion 74-75.
69. Dominguez-Escrig JL, McCracken SR, Greene D. Beyond diagnosis: evolving prostate biopsy in the era of focal therapy. Prostate Cancer. 2011;2011:386207.
70. Kvale R, Moller B, Wahlqvist R, et al. Concordance between Gleason scores of needle biopsies and radical prostatectomy specimens: a population-based study. BJU Int. 2009;103(12):1647-1654.
71. Porten SP, Whitson JM, Cowan JE, et al. Changes in prostate cancer grade on serial biopsy in men undergoing active surveillance. J Clin Oncol. 2011;29(20):2795-2800.
72. Shakir NA, Siddiqui MM, George AK, et al. Should Hypoechoic Lesions on Transrectal Ultrasound Be Sampled During Magnetic Resonance Imaging-targeted Prostate Biopsy?. Urology. 105:113-117, 2017 Jul.
73. Keetch DW, Catalona WJ, Smith DS. Serial prostatic biopsies in men with persistently elevated serum prostate specific antigen values. J Urol. 1994;151(6):1571-1574.
74. Ploussard G, Nicolaiew N, Marchand C, et al. Risk of repeat biopsy and prostate cancer detection after an initial extended negative biopsy: longitudinal follow-up from a prospective trial. BJU Int. 2013;111(6):988-996.
75. Roehl KA, Antenor JA, Catalona WJ. Serial biopsy results in prostate cancer screening study. J Urol. 2002;167(6):2435-2439.
76. Vencalek O, Facevicova K, Furst T, Grepl M. When less is more: a simple predictive model for repeated prostate biopsy outcomes. Cancer Epidemiol. 2013;37(6):864-869.
77. Zaytoun OM, Stephenson AJ, Fareed K, et al. When serial prostate biopsy is recommended: most cancers detected are clinically insignificant. BJU Int. 2012;110(7):987-992.
78. KandaSwamy GV, Bennett A, Narahari K, Hughes O, Rees J, Kynaston H. Establishing the pathways and indications for performing isotope bone scans in newly diagnosed intermediate-risk localised prostate cancer - results from a large contemporaneous cohort. BJU Int. 120(5B):E59-E63, 2017 11.
79. Wondergem M, van der Zant FM, Knol RJJ, et al. 99mTc-HDP bone scintigraphy and 18F-sodiumfluoride PET/CT in primary staging of patients with prostate cancer. World J Urol. 36(1):27-34, 2018 Jan.
80. Suh CH, Shinagare AB, Westenfield AM, Ramaiya NH, Van den Abbeele AD, Kim KW. Yield of bone scintigraphy for the detection of metastatic disease in treatment-naive prostate cancer: a systematic review and meta-analysis. [Review]. Clin Radiol. 73(2):158-167, 2018 02.
81. Cantiello F, Russo GI, Kaufmann S, et al. Role of multiparametric magnetic resonance imaging for patients under active surveillance for prostate cancer: a systematic review with diagnostic meta-analysis. Prostate Cancer Prostatic Dis. 22(2):206-220, 2019 05.
82. Amin A, Scheltema MJ, Shnier R, et al. The Magnetic Resonance Imaging in Active Surveillance (MRIAS) Trial: Use of Baseline Multiparametric Magnetic Resonance Imaging and Saturation Biopsy to Reduce the Frequency of Surveillance Prostate Biopsies. J Urol. 203(5):910-917, 2020 05.
83. Henderson DR, de Souza NM, Thomas K, et al. Nine-year Follow-up for a Study of Diffusion-weighted Magnetic Resonance Imaging in a Prospective Prostate Cancer Active Surveillance Cohort. Eur Urol. 69(6):1028-33, 2016 06.
84. Kornberg Z, Cowan JE, Westphalen AC, et al. Genomic Prostate Score, PI-RADS TM version 2 and Progression in Men with Prostate Cancer on Active Surveillance. J Urol. 201(2):300-307, 2019 02.
85. Bryant RJ, Yang B, Philippou Y, et al. Does the introduction of prostate multiparametric magnetic resonance imaging into the active surveillance protocol for localized prostate cancer improve patient re-classification?. BJU Int. 122(5):794-800, 2018 11.
86. Bloom JB, Hale GR, Gold SA, et al. Predicting Gleason Group Progression for Men on Prostate Cancer Active Surveillance: Role of a Negative Confirmatory Magnetic Resonance Imaging-Ultrasound Fusion Biopsy. J Urol. 201(1):84-90, 2019 01.
87. Arabi A, Deebajah M, Yaguchi G, et al. Systematic Biopsy Does Not Contribute to Disease Upgrading in Patients Undergoing Targeted Biopsy for PI-RADS 5 Lesions Identified on Magnetic Resonance Imaging in the Course of Active Surveillance for Prostate Cancer. Urology. 134:168-172, 2019 Dec.
88. Borkowetz A, Renner T, Platzek I, et al. Evaluation of Magnetic Resonance Imaging/Ultrasound-Fusion Biopsy in Patients with Low-Risk Prostate Cancer Under Active Surveillance Undergoing Surveillance Biopsy. Urol Int. 100(2):155-163, 2018.
89. Klotz L, Loblaw A, Sugar L, et al. Active Surveillance Magnetic Resonance Imaging Study (ASIST): Results of a Randomized Multicenter Prospective Trial. Eur Urol. 75(2):300-309, 2019 02.
90. Ma TM, Tosoian JJ, Schaeffer EM, et al. The Role of Multiparametric Magnetic Resonance Imaging/Ultrasound Fusion Biopsy in Active Surveillance. Eur Urol. 71(2):174-180, 2017 02.
91. Pepe P, Garufi A, Priolo G, Pennisi M. Can MRI/TRUS fusion targeted biopsy replace saturation prostate biopsy in the re-evaluation of men in active surveillance?. World J Urol. 34(9):1249-53, 2016 Sep.
92. Recabal P, Assel M, Sjoberg DD, et al. The Efficacy of Multiparametric Magnetic Resonance Imaging and Magnetic Resonance Imaging Targeted Biopsy in Risk Classification for Patients with Prostate Cancer on Active Surveillance. J Urol. 196(2):374-81, 2016 Aug.
93. Jung AJ, Coakley FV, Shinohara K, et al. Local staging of prostate cancer: comparative accuracy of T2-weighted endorectal MR imaging and transrectal ultrasound. Clin Imaging. 2012;36(5):547-552.
94. Eltemamy MM, Leapman MS, Cowan JE, Westphalen A, Shinohara K, Carroll PR. Serial Anatomical Prostate Ultrasound during Prostate Cancer Active Surveillance. J Urol. 196(3):727-33, 2016 Sep.
95. Zhou J, Gou Z, Wu R, Yuan Y, Yu G, Zhao Y. Comparison of PSMA-PET/CT, choline-PET/CT, NaF-PET/CT, MRI, and bone scintigraphy in the diagnosis of bone metastases in patients with prostate cancer: a systematic review and meta-analysis. Skeletal Radiol. 48(12):1915-1924, 2019 Dec.
96. Johnston EW, Latifoltojar A, Sidhu HS, et al. Multiparametric whole-body 3.0-T MRI in newly diagnosed intermediate- and high-risk prostate cancer: diagnostic accuracy and interobserver agreement for nodal and metastatic staging. Eur Radiol. 29(6):3159-3169, 2019 Jun.
97. Haran C, McBean R, Parsons R, Wong D. Five-year trends of bone scan and prostate-specific membrane antigen positron emission tomography utilization in prostate cancer: A retrospective review in a private centre. J Med Imaging Radiat Oncol. 63(4):495-499, 2019 Aug.
98. Kim SJ, Lee SW. The role of 18F-fluciclovine PET in the management of prostate cancer: a systematic review and meta-analysis. Clin Radiol. 74(11):886-892, 2019 Nov.
99. Evangelista L, Cimitan M, Zattoni F, Guttilla A, Zattoni F, Saladini G. Comparison between conventional imaging (abdominal-pelvic computed tomography and bone scan) and [(18)F]choline positron emission tomography/computed tomography imaging for the initial staging of patients with intermediate- tohigh-risk prostate cancer: A retrospective analysis. Scand J Urol. 49(5):345-53, 2015.
100. Samper Ots P, Luis Cardo A, Vallejo Ocana C, et al. Diagnostic performance of 18F-choline PET-CT in prostate cancer. Clin Transl Oncol. 21(6):766-773, 2019 Jun.
101. Metser U, Berlin A, Halankar J, et al. 18F-Fluorocholine PET Whole-Body MRI in the Staging of High-Risk Prostate Cancer. AJR Am J Roentgenol. 210(3):635-640, 2018 Mar.
102. Jambor I, Kuisma A, Kahkonen E, et al. Prospective evaluation of 18F-FACBC PET/CT and PET/MRI versus multiparametric MRI in intermediate- to high-risk prostate cancer patients (FLUCIPRO trial). Eur J Nucl Med Mol Imaging. 45(3):355-364, 2018 03.
103. Elschot M, Selnaes KM, Sandsmark E, et al. Combined 18F-Fluciclovine PET/MRI Shows Potential for Detection and Characterization of High-Risk Prostate Cancer. J Nucl Med. 59(5):762-768, 2018 05.
104. Elschot M, Selnaes KM, Sandsmark E, et al. A PET/MRI study towards finding the optimal [18F]Fluciclovine PET protocol for detection and characterisation of primary prostate cancer. Eur J Nucl Med Mol Imaging. 44(4):695-703, 2017 Apr.
105. Selnaes KM, Kruger-Stokke B, Elschot M, et al. 18F-Fluciclovine PET/MRI for preoperative lymph node staging in high-risk prostate cancer patients. Eur Radiol. 28(8):3151-3159, 2018 Aug.
106. Alemozaffar M, Akintayo AA, Abiodun-Ojo OA, et al. [18F]Fluciclovine Positron Emission Tomography/Computerized Tomography for Preoperative Staging in Patients with Intermediate to High Risk Primary Prostate Cancer. J Urol. 204(4):734-740, 2020 10.
107. Sheikhbahaei S, Jones KM, Werner RA, et al. 18F-NaF-PET/CT for the detection of bone metastasis in prostate cancer: a meta-analysis of diagnostic accuracy studies. Ann Nucl Med. 33(5):351-361, 2019 May.
108. Gauthe M, Aveline C, Lecouvet F, et al. Impact of sodium 18F-fluoride PET/CT, 18F-fluorocholine PET/CT and whole-body diffusion-weighted MRI on the management of patients with prostate cancer suspicious for metastasis: a prospective multicentre study. World J Urol. 37(8):1587-1595, 2019 Aug.
109. Cooperberg MR, Cowan JE, Hilton JF, et al. Outcomes of active surveillance for men with intermediate-risk prostate cancer. J Clin Oncol. 2011;29(2):228-234.
110. Raldow AC, Zhang D, Chen MH, Braccioforte MH, Moran BJ, D'Amico AV. Risk Group and Death From Prostate Cancer: Implications for Active Surveillance in Men With Favorable Intermediate-Risk Prostate Cancer. JAMA Oncol. 2015;1(3):334-340.
111. Carlsson S, Benfante N, Alvim R, et al. Risk of Metastasis in Men with Grade Group 2 Prostate Cancer Managed with Active Surveillance at a Tertiary Cancer Center. J Urol. 203(6):1117-1121, 2020 06.
112. Beksac AT, Sobotka S, Xu P, et al. Downgrading of Grade Group After Radical Prostatectomy: Comparison of Multiparametric Magnetic Resonance Imaging Guided Fusion Biopsy and Standard 12-Core Biopsy. Urology. 127:80-85, 2019 05.
113. Woo S, Kim SY, Kim SH, Cho JY. JOURNAL CLUB: Identification of Bone Metastasis With Routine Prostate MRI: A Study of Patients With Newly Diagnosed Prostate Cancer. AJR Am J Roentgenol. 206(6):1156-63, 2016 Jun.
114. Hricak H, Wang L, Wei DC, et al. The role of preoperative endorectal magnetic resonance imaging in the decision regarding whether to preserve or resect neurovascular bundles during radical retropubic prostatectomy. Cancer. 2004; 100(12):2655-2663.
115. Muglia VF, Westphalen AC, Wang ZJ, Kurhanewicz J, Carroll PR, Coakley FV. Endorectal MRI of prostate cancer: incremental prognostic importance of gross locally advanced disease. AJR Am J Roentgenol. 2011;197(6):1369-1374.
116. Robertson NL, Sala E, Benz M, et al. Combined Whole Body and Multiparametric Prostate Magnetic Resonance Imaging as a 1-Step Approach to the Simultaneous Assessment of Local Recurrence and Metastatic Disease after Radical Prostatectomy. J Urol. 198(1):65-70, 2017 07.
117. Tulsyan S, Das CJ, Tripathi M, Seth A, Kumar R, Bal C. Comparison of 68Ga-PSMA PET/CT and multiparametric MRI for staging of high-risk prostate cancer68Ga-PSMA PET and MRI in prostate cancer. Nucl Med Commun. 38(12):1094-1102, 2017 Dec.
118. Han S, Woo S, Kim YJ, Suh CH. Impact of 68Ga-PSMA PET on the Management of Patients with Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol. 74(2):179-190, 2018 08.
119. Hofman MS, Lawrentschuk N, Francis RJ, et al. Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study. Lancet. 395(10231):1208-1216, 2020 04 11.
120. Lengana T, Lawal IO, Boshomane TG, et al. 68Ga-PSMA PET/CT Replacing Bone Scan in the Initial Staging of Skeletal Metastasis in Prostate Cancer: A Fait Accompli?. Clin Genitourin Cancer. 16(5):392-401, 2018 10.
121. Maurer T, Gschwend JE, Rauscher I, et al. Diagnostic Efficacy of (68)Gallium-PSMA Positron Emission Tomography Compared to Conventional Imaging for Lymph Node Staging of 130 Consecutive Patients with Intermediate to High Risk Prostate Cancer. J Urol. 195(5):1436-1443, 2016 May.
122. Thalgott M, Duwel C, Rauscher I, et al. One-Stop-Shop Whole-Body 68Ga-PSMA-11 PET/MRI Compared with Clinical Nomograms for Preoperative T and N Staging of High-Risk Prostate Cancer. Journal of Nuclear Medicine. 59(12):1850-1856, 2018 12.
123. Kuten J, Fahoum I, Savin Z, et al. Head-to-Head Comparison of 68Ga-PSMA-11 with 18F-PSMA-1007 PET/CT in Staging Prostate Cancer Using Histopathology and Immunohistochemical Analysis as a Reference Standard. J Nucl Med. 61(4):527-532, 2020 04.
124. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.
Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.