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ACR Appropriateness Criteria®

Posttreatment Follow-up ofProstate Cancer

David D. Casalino, MDa, Erick M. Remer, MDb, Ronald S. Arellano, MDc,Jay T. Bishoff, MDd,e, Courtney A. Coursey, MDf, Manjiri Dighe, MDg,

Douglas F. Eggli, MDh,i, Pat Fulgham, MDe,j, Gary M. Israel, MDk,Elizabeth Lazarus, MDl, John R. Leyendecker, MDm, Paul Nikolaidis, MDa,

Nicholas Papanicolaou, MDn, Srinivasa Prasad, MDo, Parvati Ramchandani, MDn,Sheila Sheth, MDp, Raghunandan Vikram, MDq

Although prostate cancer can be effectively treated, recurrent or residual disease after therapy is not uncommonand is usually detected by a rise in prostate-specific antigen. Patients with biochemical prostate-specific antigenrelapse should undergo a prompt search for the presence of local recurrence or distant metastatic disease, eachrequiring different forms of therapy. Various imaging modalities and image-guided procedures may be used inthe evaluation of these patients. Literature on the indications and usefulness of these radiologic studies andprocedures in specific clinical settings is reviewed.

The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that arereviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include anextensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatmentprocedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion maybe used to recommend imaging or treatment.

Key Words: Appropriateness Criteria, prostate, prostate cancer, posttreatment, imaging

J Am Coll Radiol 2011;8:863-871. Copyright © 2011 American College of Radiology

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SUMMARY OF LITERATURE REVIEWIn evaluating patients with recurrent or metastatic pros-tate cancer, it is important to define the location, size,and extent of local and/or distant tumors. Prostate canceris treated using 4 standard methods: radical prostatec-tomy, radiation therapy, androgen deprivation therapy

aNorthwestern University, Chicago, Illinois.bCleveland Clinic, Cleveland, Ohio.cMassachusetts General Hospital, Boston, Massachusetts.dIntermountain Urological Institute, Murray, Utah.eAmerican Urological Association, Linthicum, Maryland.fEmory University Hospital, Atlanta, Georgia.gUniversity of Washington Medical Center, Seattle, Washington.hPennsylvania State University, Hershey, Pennsylvania.iSociety of Nuclear Medicine, Reston, Virginia.jPresbyterian Hospital of Dallas, Dallas, Texas.kYale University School of Medicine, New Haven, Connecticut.lRhode Island Hospital, Providence, Rhode Island.mWake Forest University School of Medicine, Winston Salem, North Caro-

lina.

2011 American College of Radiology091-2182/11/$36.00 ● DOI 10.1016/j.jacr.2011.09.003

ADT), and active surveillance. The treatment choice isased on the tumor stage, histology, and grade and isnfluenced to a certain extent by the preference of thereating physician and the patient. After treatment, pa-ients are followed at periodic intervals with measure-ent of serum prostate-specific antigen (PSA) levels and

nHospital of University of Pennsylvania, Philadelphia, Pennsylvania.oUniversity of Texas Health Science Center, San Antonio, Texas.pJohns Hopkins Hospital, Baltimore, Maryland.qUniversity of Texas M. D. Anderson Cancer Center, Houston, Texas.

Corresponding author and reprints: David D. Casalino, MD, Americanollege of Radiology, 1891 Preston White Drive, Reston, VA 20191; e-mail:avid.casalino@nmff.org.

The ACR seeks and encourages collaboration with other organizations onhe development of the ACR Appropriateness Criteria® through society rep-esentation on expert panels. Participation by representatives from collaborat-ng societies on the expert panel does not necessarily imply society endorse-

ent of the final document.

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864 Journal of the American College of Radiology/Vol. 8 No. 12 December 2011

digital rectal examination (DRE). However, DRE is fre-quently unreliable in evaluating local recurrent diseaseafter radical prostatectomy [1]. Although radical prosta-tectomy and radiation therapy are considered definitivetherapies, 30% to 50% of patients will have biochemicalPSA relapse at 5 years [2].

Prostate-specific antigen is produced by the epithelialcells of the prostate gland and is considered specific forprostatic tissue, although there is low-level extraprostaticPSA production in the epithelial cells of other organs [3].A rise in PSA is detected in the serum when the prostategland has been disrupted, as with prostate cancer, benignprostatic hyperplasia, and acute prostatitis or after pros-tate biopsy. Prostate-specific antigen is now widely usedas a tumor marker for prostate cancer, both for detectionand for monitoring response to therapy. No imagingstudy is necessary after treatment for clinically localizedprostate cancer unless PSA is elevated, DRE results areabnormal, or the patient has bone pain [1].

Although PSA alone does not differentiate local fromdistant disease recurrence, the patterns of PSA increaseafter local therapy have been incorporated into clinicalnomograms to predict whether recurrence is more likelylocal or distal metastatic disease. Patients with late bio-chemical recurrence (�24 months after local treatment),low PSA velocity (change in PSA over time), and/orprolonged PSA doubling time (PSADT; �6 months)most likely have recurrent local disease [4]. Conversely,patients with a rapid PSA recurrence (�24 months afterlocal treatment), high PSA velocity, or short PSADT(�6 months) are more likely to have distant disease re-currence [4].

A number of clinical nomograms have used PSA valuesand PSA kinetics to predict positive imaging results [5-8]. Choueiri et al [9], for example, presented a model thatpredicts the probability of positive imaging in patientswith prostate cancer with biochemical failure after defin-itive therapy with prostatectomy or radiation therapyand concluded that imaging studies are unlikely to beuseful when trigger PSA (ie, the last PSA level beforeimaging) is �5 ng/mL and the PSADT is �10 months.The study also concluded that there is no definitive trig-ger PSA or PSA kinetic parameter that has a high enoughpositive predictive value to recommend for or againstdiagnostic imaging.

Bone radiography is not as sensitive for detecting me-tastasis as radionuclide bone scans, but it may be helpfulin identifying degenerative changes as the cause for pos-itive bone scan results. Chest radiography is not necessarybecause lung metastases are found only in late-stage dis-ease, after other, more common sites are involved bytumor.

Whole-body bone scans are frequently performed todetect skeletal metastases in patients with rising PSA aftertreatment. If the results of a bone scan are positive for

metastatic disease, no other imaging is indicated. Because o

one scan results are rarely positive without symptoms orithout abnormal PSA levels, the routine use of this

tudy after treatment is considered unproductive by mostnvestigators [10-12]. The results of a bone scan may benconclusive, because it is a sensitive but not specificxamination. MRI may be helpful in the diagnosis ofone metastasis when other examinations are conflicting,nd it can be used to determine response to hormonalreatment [13].

Post Radical ProstatectomyAfter radical prostatectomy, PSA levels are expected to beundetectable to �0.15 ng/mL within several weeks ofsurgery. According to the Clinical Practice Guidelines inOncology for prostate cancer developed by the NationalComprehensive Cancer Network [14], patients whosePSA levels fail to fall to undetectable levels or with de-tectable PSA increases on two subsequent measurementsshould undergo a prompt search for the presence of dis-tant metastatic disease or local recurrent disease, eachrequiring different forms of systemic or local therapy. Ifdistant metastases are detected, ADT is typically initi-ated.

Radionuclide Bone Scintigraphy. A radionuclide bonescan is traditionally the first examination performed. Ifthe results are positive for metastatic disease, no furtherimaging studies are necessary. If the results are inconclu-sive, further imaging studies are performed, includingconventional radiography, MRI, or CT. However, thelevel of posttreatment PSA that should prompt a bonescan is uncertain. In a study of patients with biochemicalfailure after radical prostatectomy, the probability of pos-itive results on bone scan was �5% with PSA levelsbetween 40 and 45 ng/mL. Men with PSADTs � 6months after radical prostatectomy were at increased riskfor positive bone scan results (26% vs 3%) comparedwith those with longer PSADTs [8]. Kane et al [7] re-ported that most patients with positive results on bonescans had high PSA levels (mean, 61.3 ng/mL) and highPSA velocities (�0.5 ng/mL/month).

According to the American Urological Association’sProstate-Specific Antigen Best Practice Statement, the rou-tine use of bone scans in the setting of an increase in PSAis not justified, particularly in patients with PSADTs � 6

onths and PSA levels � 10 ng/mL [15].

Transrectal Ultrasound. The use of imaging in evaluat-ng local tumor recurrence is controversial. Local recur-ences are most often perianastomotic or retrovesical,ites that can be evaluated using ultrasound. Transrectalltrasound (TRUS) with guided biopsy of the vesicoure-hral anastomosis has been the standard imaging ap-roach to document local recurrence [16,17]. A palpablebnormality on DRE is not always a good guide to theocation of recurrent or progressive tumor because post-

perative fibrosis may mimic tumor [18]. Negative re-

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sults of ultrasound-guided transrectal biopsy of the vesi-courethral anastomosis may be inconclusive because ofsampling error. Deliveliotis et al [19] reported negative

redictive values of only 67% with TRUS-guided biopsynd 57% with DRE-guided biopsy in patients with PSAevels � 2 ng/mL and negative imaging results for me-astases after prostatectomy. The use of biopsy has beenuestioned in the face of a rising PSA level because theegative results are unreliable and elevated PSA levelssually precede clinical evidence of local recurrence by1 year. Repeat TRUS with vesicourethral anastomosis

eedle biopsy may be necessary in one-third of cases20,21]. The yield for detecting local recurrent tumorith TRUS with needle biopsy rises significantly with

erum PSA levels [19,20,22,23].Several studies have shown the utility of color and

ower Doppler and contrast-enhanced color Doppler inetecting local recurrence after prostatectomy [24-26].rudi et al [24] showed that contrast-enhanced coloroppler TRUS performed as well as contrast-enhancedRI in detecting local recurrence after prostatectomy;

owever, intravascular microbubble contrast agents areot yet FDA approved for this application.

CT. CT is not effective for detecting recurrent tumor inthe surgical bed [27]. A CT scan can recognize only localrecurrences that are �2 cm [28]. The mean PSA valueassociated with positive CT results after radical prosta-tectomy was 27.4 ng/mL [7].

In the evaluation of nodal disease, CT has replacedlymphography and relies on nodal size to detect nodalmetastases. Using 1 cm as a cutoff, studies have reportedsensitivity between 27% and 75% and specificity be-tween 66% and 100% [29]. CT is useful in detectingbone and visceral metastases, although bone scan andMRI are superior in the diagnosis and follow-up of bonemetastases [30].

MRI. The use of MRI is evolving, and it can evaluateboth local recurrence and distant bony and nodal metas-tases. Although most local recurrences are perianasto-motic or retrovesical, 30% may be elsewhere in the pelvis,at sites that can be more readily assessed by MRI than byultrasound [31]. Two early studies on the use of endo-rectal coil T2-weighted MRI for detecting local recur-rence after prostatectomy reported 95% to 100% sensi-tivity and 100% specificity [31,32]. Two subsequentstudies reported that T2-weighted MRI had lower sensi-tivity (48% and 61%) and specificity (52% and 82%) fordetecting local recurrence [33,34].

More recent studies [33-35] have suggested that newerR techniques, including MR spectroscopic imaging

MRSI) and dynamic contrast-enhanced (DCE) MRI,an improve the detection of recurrence after prostatec-omy, although these techniques require specialized ac-uisition and processing software and have not been sys-

ematically evaluated [2].

Concurrent MRI-directed biopsy of suspicious sites isot widely available, making histologic correlation andssessment of its true utility difficult.

The accuracy of MRI for staging pelvic lymph nodesy size criteria is similar to that of CT. MRI can beore sensitive and specific in the diagnosis of boneetastases, with better spatial and contrast resolution

ompared with bone scan [36]. The response of boneetastases to treatment can be more accurately mon-

tored by serial MRI scans [13].

Post Radiation TherapyProstate cancer treated with radiation therapy, whetherby external beam or brachytherapy, is monitored differ-ently, because the prostate and the lymph nodes are leftin place. After radiation therapy, the serum PSA leveldecreases in the majority of patients during the first yearbut may not reach a nadir until 18 to 30 months aftertreatment. Surveillance for tumor recurrence in patientsafter radiation therapy should include a DRE and serialserum PSA levels. At the 2005 Phoenix Consensus Con-ference, ASTRO and RTOG® defined biochemical fail-ure after radiation therapy as a rise of �2 ng/ml above thenadir PSA level [37]. An increasing serum PSA level willprompt a radionuclide bone scan. If the results are posi-tive, no further evaluation is necessary. If the results arenegative or inconclusive, TRUS-directed biopsy of theprostate is indicated.

If the results of the bone scan are inconclusive, MRImay be helpful. MRI may be indicated to depict localrecurrence after radiotherapy. Sala et al [38] used endo-rectal T2-weighted MRI to evaluate cancer recurrenceafter radiation therapy and before salvage prostatectomy,and achieved sensitivities and specificities for tumor de-tection by quadrant, extracapsular extension, and semi-nal vesicle invasion similar to those obtained in studies ofuntreated patients. Pucar et al [39] found that clinicallysignificant local recurrence after radiation therapy occursat the site of the primary tumor and suggested that mon-itoring the primary tumor with MRI before and afterradiotherapy might lead to early detection of local recur-rence amenable to salvage therapy.

More recent studies have suggested that newer MRtechniques, including MRSI [40-42], DCE MRI [43-45], and diffusion-weighted imaging (DWI) [44,46],can improve the detection of recurrent prostate cancerafter radiation therapy.

Evaluation for lymph node enlargement is done byeither CT or MRI. Both imaging tests are relatively ac-curate for detecting lymph node enlargement [47].

Post ADTAndrogen deprivation therapy, using bilateral orchiec-tomy (surgical castration) or luteinizing hormone-releas-ing hormone agonist (medical castration), may control

prostate cancer for long periods by decreasing the size of

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866 Journal of the American College of Radiology/Vol. 8 No. 12 December 2011

the tumor, thus relieving pain and other symptoms inpatients with advanced disease. Androgen deprivationtherapy may have a direct suppressive effect on serumPSA level that is independent of tumor activity. Prostate-specific antigen production is under hormonal control,and ADT reduces the cell’s ability to produce and secretePSA. Therefore, serum PSA is not always a reliablemarker of disease status in these patients.

In a study by Ruckle et al [48], serial serum PSAmeasurements after ADT were able to predict response tothe treatment. Patients whose serum PSA levels remainedelevated for �3 months after treatment had a high riskfor disease progression within 2 years. Serial PSA deter-minations in combination with radionuclide bone scan-ning are clinically warranted as follow-up in these pa-tients with advanced disease. In patients treated withADT for advanced prostate cancer, an increasing serumPSA level warrants further assessment because these pa-tients may be candidates for systemic salvage therapy.The investigation can end if the results of a bone scan areconclusive. CT and MRI are useful in assessing nodal orvisceral metastatic disease.

Active SurveillanceActive surveillance involves actively monitoring thecourse of the disease with the expectation to intervene ifthe cancer progresses. Active surveillance as initial ther-apy for prostate cancer might be considered for patientswith clinically localized disease that has a low risk forrecurrence (T1 to T2a, Gleason score of 2-6, and PSAlevel � 10 ng/mL) or for patients with clinically localizeddisease that has an intermediate risk for recurrence (T2bto T2c, Gleason score of 7, or PSA level of 10-20 ng/mL)and who have a life expectancy � 10 years [14]. Surveil-ance typically consists of serum PSA levels every 3 to 6

onths, DRE every 6 to 12 months, and repeat prostateiopsy as often as annually. These studies may be done

ess frequently in patients who have life expectancy � 10years [14]. Signs of cancer progression detected by PSAor DRE usually warrant a repeat prostate biopsy. If bi-opsy confirms cancer progression, pretreatment staging isthen performed (see “ACR Appropriateness Criteria® onPretreatment Staging Prostate Cancer”).

Imaging is generally not a component of active surveil-lance, but a few recent studies have suggested that MRI mayhelp in guiding patients who are considering active surveil-lance and how the surveillance is conducted [49,50].

Newer Techniques

ProstaScint Scan (111In Capromab Pendetide). Pros-aScint is a murine monoclonal antibody that targetsrostate-specific membrane antigen. ProstaScint imag-ng in the detection of metastases and local recurrence haseen reported to have sensitivity of 49% to 94%, speci-city of 65% to 72%, and overall accuracy of 63% to

0% [51-54]. Two more recent studies concluded that in

electing patients for salvage radiotherapy for rising PSAfter radical prostatectomy for prostate cancer, rates ofesponse or biochemical control were similar betweenatients selected for radiotherapy on the basis of Prosta-cint examination and those selected on the basis oflinicopathologic factors alone [55,56].

PET with Fluorine-18-2-Fluoro-2-Deoxy-D-Glucose.Many foci of metastatic prostate cancer demonstrate

increased accumulation of FDG radiotracer, althoughthis uptake is generally low compared with the othercancers. In one study, FDG PET identified local or met-astatic disease in only 28 of 91 patients (31%) with PSArelapse after radical prostatectomy for prostate cancer[57]. PET with FDG is relatively insensitive in detectingosseous metastases compared to standard bone scintigra-phy [58].

PET with Newer Radiotracers Including [11C]-Acetate, [11Cor 18F]-Choline, Anti-1-Amino-3-[18F]-Fluorocyclobutane--Carboxylic Acid, and [11C]-Methionine. PET and

PET/CT with 11C acetate [59,60], 11C choline [61-64],18F choline [65-67], and anti-1-amino-3-[18F]-fluorocy-lobutane-1-carboxylic acid [68] have been reported toetect local and metastatic recurrent disease in patientsith biochemical failure after local treatment. PET with

11C methionine has been reported to be more sensitivehan FDG PET in detecting bone metastases [69]. Theseewer agents remain experimental and are not widelyvailable.

MRI at 3 T. Magnetic resonance scanners operating at 3T are now commercially available and offer higher signal-to-noise ratios, faster acquisition times, and higher spa-tial resolution than lower field MR systems. These 3-Tsystems are being used to evaluate patients with prostatecancer, but few studies have been published. Althoughthere is general agreement that optimal prostate imagingat 1.5 T, particularly when including spectroscopy andDWI, requires the use of an endorectal coil, the necessityto use an endorectal coil with a 3-T system is uncertain atthis time [70,71].

MRSI. Magnetic resonance spectroscopic imaging pro-vides metabolic information from 3-D multiple contig-uous volumes (voxels) within the prostate gland, andprostate cancers typically show decreased citrate peak andan increased choline/creatine peak compared with nor-mal prostatic tissues on MRSI [72]. The addition of themetabolic information provided by MRSI to the mor-phologic information provided by endorectal coil MRIcan help detect local tumor recurrence after prostatec-tomy [35] and discriminate regions of residual tumorrom other prostatic tissues and necrosis after radiationherapy [40-42].

DCE MRI. Dynamic contrast-enhanced MRI is a well-

established method for detecting and quantifying angio-

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genesis in tumors, including prostate cancer, and is inde-pendent of T2 relaxation and MRSI characteristics. Sitesof tumor typically show earlier, more intense enhance-ment and earlier, more rapid contrast washout comparedwith the normal peripheral zone.

Sciarra et al [35] reported the use of DCE MRI andMRSI for detecting local recurrence in patients with bio-chemical failure after prostatectomy and concluded thatthe combination of techniques was superior to eithertechnique alone (sensitivity and specificity of 87% and94% for combination, 84% and 88% for MRSI, and71% and 94% for DCE MRI in 47 patients who hadreliable TRUS biopsies). Casciani et al [33] studied 46patients (25 with local recurrence) and showed that MRIcombined with DCE MRI had higher sensitivity andspecificity (88% and 100%) than MRI alone (48% and52%) in detecting local recurrences after prostatectomy.

Haider et al [43] found that DCE MRI performedbetter than T2-weighted imaging for detecting and local-

Variant 1. Status postradical prostatectomy; rising PSA lRadiologic Procedure Rating

99mTc bone scan whole body 8 More likely toPSADT � 6Correlative rbone scan isworkup is ne

CT abdomen and pelvis withcontrast

7 For nodal invorecurrence.

MRI pelvis without and with contrast 7 Depends on aEndorectal cevaluating loinvolvementpromising inguided biopstatement re“Anticipated

MRI abdomen and pelvis withoutand with contrast

7 Depends on aEndorectal cevaluating loinvolvementpromising inguided biop

Ultrasound-guided biopsy prostatebed transrectal

6 Should be donrecurrence.visualized onof cases.

Ultrasound pelvis (prostate)transrectal

4

ProstaScint scan 3 May be more alocal therapyimaging with

FDG PET whole body 3 PET/CT is prowarrant rout

Ultrasound pelvis (prostate)transabdominal

2

X-ray radiographic survey wholebody

1

Note: Rating scale: 1, 2, and 3 � usually not appropriate; 4, 5, and 6 � ma

antigen; PSADT � prostate-specific antigen doubling time.

izing cancer in the peripheral zone after external-beamradiation, with sensitivity, positive predictive value, neg-ative predictive value of 72%, 46%, and 95%, respec-tively, for DCE MRI vs 38%, 24%, and 88%, respec-tively, for T2-weighted imaging. Kim et al [44] studied24 patients with rising PSA levels after external-beamradiotherapy for prostate cancer and found the sensitiv-ity, specificity, and accuracy of DCE, DWI, and com-bined DCE and DWI were higher than those for T2-weighted imaging for predicting locally recurrent cancer.

Although the results of these studies have been encour-aging, there is not a uniformly accepted analytic methodfor DCE MRI. Multi-institutional studies are needed.

DWI MRI. Diffusion-weighted imaging MRI is a tech-ique sensitive to water diffusion restriction. Prostateancer can cause restricted diffusion relative to normalrostatic tissue, resulting in increased signal of prostateancer on DWI and decreased pixel values on apparent

lComments Relative Radiation Level

helpful if PSA � 10 ng/mL ornths. Readily available.ographs may be necessary. Ifsitive, no further imaging

ssary.ent. Not very useful for local

ability and institutional expertise.MRI may be useful forextension or pelvic nodale of gadolinium injection istecting local recurrence. MRI-s not widely available. Seeding contrast in text underceptions.”

O

ability and institutional expertise.MRI may be useful forextension or pelvic nodale of gadolinium injection istecting local recurrence. MRI-s not widely available.

O

nder US guidance to confirmal recurrent tumor may bensrectal US in only 30%-50%

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or MRI has been reported.ing, but data are insufficient touse.

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868 Journal of the American College of Radiology/Vol. 8 No. 12 December 2011

diffusion coefficient maps. Kim et al [46] studied 36atients and found that T2-weighted imaging combinedith DWI had higher sensitivity and specificity (62%

nd 97%) than T2-weighted imaging alone (25% and2%) for predicting locally recurrent prostate cancer inatients with biochemical failure after external-beamadiotherapy.

Newer Lymph Nodal MR Contrast Agent. Magneticresonance imaging after the intravenous administrationof lymphotropic superparamagnetic iron oxide nanopar-ticles has been reported to improve the detection of pos-itive lymph nodal metastases from prostate cancer com-pared with unenhanced MRI [73]. This MRI contrastagent, however, is not yet FDA approved.

Variant 2. Status postradiation therapy; rising PSA levelRadiologic Procedure Rating

99mTc bone scan whole body 8 CorrelativeCT abdomen and pelvis with contrast 7MRI pelvis without and with contrast 7 Depends o

expertispromisinstateme“Anticip

MRI abdomen and pelvis without and withcontrast

7 Depends oexpertisin text u

Ultrasound-guided biopsy prostate bedtransrectal

6

Ultrasound pelvis (prostate) transrectal 3ProstaScint scan 3FDG PET whole body 3Ultrasound pelvis (prostate) transabdominal 1X-ray radiographic survey whole body 1

Note: Rating scale: 1, 2, and 3 � usually not appropriate; 4, 5, and 6 � maantigen.

Variant 3. Treatment of metastatic prostate cancer by anRadiologic Procedure Rating

99mTc bone scan whole body 8 Obtain radioCT abdomen and pelvis with contrast 7MRI pelvis without and with contrast 7 Depends on

expertise.in text un

MRI abdomen and pelvis without andwith contrast

7 Depends onexpertise.in text un

ProstaScint scan 2FDG PET whole body 2Ultrasound pelvis (prostate) transrectal 1Ultrasound-guided biopsy prostate

bed transrectal1

Ultrasound pelvis (prostate)transabdominal

1

X-ray radiographic survey whole body 1

Note: Rating scale: 1, 2, and 3 � usually not appropriate; 4, 5, and 6 � may

SUMMARY

● All patients treated for prostate cancer are monitoredwith serial PSA measurements and DRE.

● A rising PSA level usually prompts a bone scan. If theresults are positive, no other imaging is generallyindicated.

● Negative or equivocal bone scan results require furtherinvestigation that may include TRUS-guided biopsy ofthe prostatectomy site or prostate and CT or MRI to searchfor regional lymphadenopathy or distant metastases.

● The role of MRI in diagnosing local recurrent diseaseand distant metastases is evolving, and more recentstudies using new techniques, including MRSI, DCEMRI, and DWI, and higher field strength scannershave shown encouraging results.

Comments Relative Radiation Leveldiography may be necessary.

vailability and institutionalse of gadolinium injection is

n detecting local recurrence. Seeegarding contrast in text underd Exceptions.”

O

vailability and institutionalee statement regarding contrastr “Anticipated Exceptions.”

O

O

O

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e appropriate; 7, 8, and 9 � usually appropriate. PSA � prostate-specific

gen deprivation therapy; rising PSA levelComments Relative Radiation Level

phs as needed.

ailability and institutionale statement regarding contrast“Anticipated Exceptions.”

O

ailability and institutionale statement regarding contrast“Anticipated Exceptions.”

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● Although ProstaScint and FDG PET have shown lim-ited utility, there are newer, experimental radiotracersthat have shown more promising initial results (seeVariants 1 to 3).

ANTICIPATED EXCEPTIONSNephrogenic systemic fibrosis is a disorder with acleroderma-like presentation and a spectrum of man-festations that can range from limited clinical se-uelae to fatality. It seems to be related to both under-ying severe renal dysfunction and the administrationf gadolinium-based contrast agents. It has occurredrimarily in patients on dialysis, rarely in patients withery limited glomerular filtration rates (ie, �30 mL/

min/1.73 m2), and almost never in other patients.There is growing literature regarding nephrogenic sys-temic fibrosis. Although some controversy and lack ofclarity remain, there is a consensus that it is advisableto avoid all gadolinium-based contrast agents in dial-ysis-dependent patients unless the possible benefitsclearly outweigh the risk and to limit the type andamount in patients with estimated glomerular filtra-tion rates � 30 mL/min/1.73 m2. For more informa-tion, please see the ACR’s Manual on Contrast Media[74].

RELATIVE RADIATION LEVEL INFORMATIONPotential adverse health effects associated with radiationexposure are an important factor to consider when select-ing the appropriate imaging procedure. Because there is awide range of radiation exposures associated with differ-ent diagnostic procedures, an relative radiation level in-dication has been included for each imaging examina-tion. The relative radiation levels are based on effectivedose, which is a radiation dose quantity that is used toestimate population total radiation risk associated withan imaging procedure. Patients in the pediatric age groupare at inherently higher risk from exposure, both becauseof organ sensitivity and longer life expectancy (relevant tothe long latency that appears to accompany radiationexposure). For these reasons, the relative radiation level

Table 1. Relative radiation level designationsRelative

RadiationLevel

Adult EffectiveDose EstimateRange (mSv)

Pediatric EffectiveDose EstimateRange (mSv)

O 0 0�0.1 �0.03

�0.1-1 0.03-0.31-10 0.3-3

10-30 3-1030-100 10-30

Note: Relative radiation level assignments for some of the examinationscannot be made, because the actual patient doses in these proceduresvary as a function of a number of factors (eg, region of the body exposedto ionizing radiation, the imaging guidance that is used). The relative

radiation levels for these examinations are designated as not specified.

ose estimate ranges for pediatric examinations are lowerompared with those specified for adults (Table 1). Ad-itional information regarding radiation dose assessmentor imaging examinations can be found in ACR Appro-riateness Criteria®: Radiation Dose Assessment Introduc-ion [75].

This article is a revised version of the ACR Appropri-teness Criteria® Post-Treatment Follow-Up of Prostateancer. Practitioners are encouraged to refer to the com-lete version at http://www.acr.org/ac.

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