Reports from the 2023 SNMMI Annual Meeting showed that PSMA PET has been adopted and integrated into the standard of care at a number of major academic centers. Still, there are some uncertainties regarding how best to apply the body of evidence on systemic therapies to the care of patients who are now being staged using PSMA PET. High-profile, practice-informing trials, including those from more than a decade ago, have utilized conventional imaging only. 

In more advanced disease settings, the US Food and Drug Administration approval of lutetium Lu 177 vipivotide tetraxetan (also referred to as ¹⁷⁷Lu-PSMA-617) for the treatment of metastatic castration-resistant prostate cancer (mCRPC) was expected to hasten the uptake of next-generation imaging, given the need to demonstrate tumoral PSMA positivity. Indeed, reports from this year's SNMMI conference did include early institutional experiences with ¹⁷⁷Lu-PSMA-617. For example, Novello and colleagues, from the Icahn School of Medicine at Mount Sinai, noted that observations from their institution largely support the use of ¹⁷⁷Lu-PSMA-617 as an emerging treatment option for patients with mCRPC (poster P1168).

In earlier disease settings, among those who undergo radical prostatectomy and experience disease progression, there is now widespread support for the use of PSMA PET to help identify lesions within the prostate bed or at more distant sites. Additionally, noting the increased sensitivity and specificity of PSMA PET tracers compared with conventional imaging, contemporary guidelines have positioned PSMA PET as an alternative to standard imaging of bone and soft tissue, with more recent guidelines also incorporating PSMA PET into the initial staging of unfavorable intermediate-risk T2b and GS7 and/or PSA 10-20 disease.

In other disease presentations, additional research is expected to shed light on the optimal use of PSMA PET. For instance, at the SNMMI meeting, researchers sought to add to what is already known about the prognostic value of PSMA PET in chemotherapy-naive patients. In poster P1138, for instance, the authors presented data from their retrospective, single-center, post hoc analysis of patients with CRPC from 6 prospective studies of PSMA PET/computed tomography (CT). This study explored the prognostic value of PSMA PET/CT for outcomes among individuals who did not receive previous chemotherapy or radionuclide therapy but did receive prior androgen receptor signaling inhibitor therapy. Researchers concluded that, in such men with CRPC, PSMA PET/CT can provide prognostic value for radiological progression after systemic treatment.

The transition to a next-generation imaging paradigm is expected to continue to unfold as new agents and new theranostics begin to emerge. The clinical trials VISION and TheraP both report the efficacy of ¹⁷⁷Lu-PSMA-617 therapy utilizing ⁶⁸Ga-PSMA-11 PET/CT imaging for patient selection. Although ⁶⁸Ga-PSMA-11 received US Food and Drug Administration approval prior to ¹⁸F-DCFPyL PSMA PET/CT, they are both currently available, and there is interest in whether the latter can be used much like ⁶⁸Ga-PSMA-11 to identify those patients who would be appropriate candidates for ¹⁷⁷Lu-PSMA-617 treatment. This concept was explored by Kim et al at the SNMMI meeting in poster P1249. Still, other PSMA PET imaging tracers and PSMA-targeted radioligands are in development that may have additional impacts on the transition to a next-generation imaging paradigm.