How to cite: Albala DM. Optimal Patient Selection and Exclusion for MTI. Grand Rounds in Urology. February 2026. Accessed Oct 2026. https://grandroundsinurology.com/optimal-patient-selection-and-exclusion-for-mti/
Summary
David M. Albala, MD, Chief of Urology, Crouse Hospital, Syracuse, New York, reviews the evidence supporting prostate-specific membrane antigen positron emission tomography (PSMA PET) for initial staging and biochemical recurrence, clarifying appropriate patient selection and clinical scenarios in which its use is not recommended.
PSMA PET is described as a versatile molecular imaging platform, particularly in targeting prostate cancer. Conventional staging with computed tomography and bone scintigraphy has historically guided management, but PSMA PET has emerged as a more sensitive and specific modality.
Randomized evidence from the proPSMA trial demonstrates superior diagnostic accuracy compared with conventional imaging, including fewer equivocal findings, higher inter-reader agreement, lower radiation exposure, and more frequent management changes. Across studies, PSMA imaging alters treatment plans in approximately 20% of patients.
In initial staging specificity for nodal disease is high, particularly in larger lymph nodes. Detection rates increase with higher disease risk. In biochemical recurrence detection rates correlate with prostate-specific antigen levels, with substantial positivity even at low values. Identification of oligometastatic disease supports consideration of metastasis-directed therapy or intensified systemic treatment.
Dr. Albala emphasizes appropriate exclusions. Routine PSMA imaging is not recommended in non-metastatic castration-resistant prostate cancer, as clinical benefit and management impact remain unclear. It is also not routinely advised for response assessment outside investigational settings.
Theranostic applications are reviewed, including radioligand therapy with lutetium-177–labeled agents and alpha-emitters such as radium-223 and actinium-225. PSMA imaging enables patient selection for these targeted approaches.
Dr. Albala stresses that PSMA PET is now the standard for initial staging and biochemical recurrence, with ongoing randomized trials evaluating its long-term impact.
The International Prostate Cancer Update (IPCU), is a multi-day, CME-accredited conference focused on new developments in prostate cancer treatment, diagnosis, and prevention. IPCU 36 will feature lectures, interactive discussions, panel roundtables, debates, and case reports. This conference is led by expert physicians and is designed for urologists, medical oncologists, radiation oncologists, and other healthcare professionals involved in the diagnosis and treatment of prostate cancer.
The goal of this educational program is to equip healthcare professionals involved in the diagnosis and treatment of prostate cancer with the up-to-date clinical knowledge and tools they need to best treat their patients. The program will discuss the treatment of prostate cancer from diagnosis to treating advanced and metastatic disease. The conference aims to give physicians exposure to a comprehensive review of treating prostate cancer patients and to give them a chance to discuss the issues with peers and experts.
ABOUT THE AUTHOR
David M. Albala, MD, is a Chief of Urology at Crouse Hospital in Syracuse, New York. Dr. Albala is considered a national and international authority in laparoscopic and robotic urological surgery. His clinical interests include minimally invasive treatments for benign prostatic hypertrophy (BPH), the use of fibrin sealants in surgery, and robotic urologic surgery.
Dr. Albala earned his medical degree at Michigan State University in East Lansing. He completed a residency in Surgery at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. He then completed a fellowship in Endourology at Washington University in St. Louis, Missouri. Under the direction of Ralph V. Clayman, Dr. Albala was part of the team that performed the first laparoscopic nephrectomy in humans.
Dr. Albala is a past White House Fellow (1995-1996), who acted as a special assistant to Federico Peña, Secretary of Transportation, on classified and unclassified public health related issues. He has been a visiting professor at numerous institutions across the United States as well as overseas in countries such as India, China, Iceland, Germany, France, Japan, Brazil, Australia, and Singapore. He has done operative demonstrations in over 32 countries and 23 states. Dr. Albala has over 215 publications in peer-reviewed journals and has authored 3 textbooks in endourology and 4 books in general urology. He is currently the Editor-in-Chief of the Journal of Robotic Surgery and serves on the editorial board for Current Opinions in Urology, Reviews in Urology, and Urology Index and Reviews. In addition, he serves as a reviewer for 8 other surgical journals. He is currently on the Board of Directors of the Large Urology Group Practice Association (LUGPA). Dr. Albala is also currently the Visiting Professor of Urology at SUNY Downstate Health Sciences University, College of Medicine. Dr. Albala has been identified (by a Stanford University-led study) as one of the top 2% of scientists in the world.
