Laboratory Tests and Imaging Studies to Detect Prostate Cancer Spread

Initial Laboratory Tests

Complete blood count and chemistry profile, including alkaline phosphatase, should be performed as part of the initial workup to assess for the presence of regional or distant metastases, as recommended by the National Comprehensive Cancer Network 1
Elevated alkaline phosphatase may indicate bone metastases and should prompt further investigation with bone imaging, according to the National Comprehensive Cancer Network 1

Chest radiograph or CT scan should be performed to evaluate for lung metastases, as recommended by the National Comprehensive Cancer Network 1
Bone scan is indicated in patients with elevated alkaline phosphatase, as recommended by the National Comprehensive Cancer Network 1
CT or MRI scan of the abdomen and pelvis should be performed to assess local tumor invasion, lymph node involvement, and spread to visceral organs, as recommended by the National Comprehensive Cancer Network 1 and the Journal of Clinical Oncology 3
Abdominal and pelvic CT scan is specifically recommended for patients with T2a stage disease or higher, PSA concentration >15 ng/mL, or Gleason score ≥7, although the source of this recommendation is not a preferred journal 2

PSMA PET/CT is now recommended as the preferred imaging modality when available, particularly for high-risk disease, by the European Urology 4
PSMA PET/CT has significantly higher accuracy than conventional imaging for detecting visceral metastases, as reported by the Journal of Clinical Oncology 3

Prostate cancer spread should be classified according to the following patterns: locally recurrent disease, nodal spread within the pelvis, nodal spread beyond the pelvis, and visceral disease, as recommended by the Journal of Clinical Oncology 3

Molecular biomarkers in metastatic lesions can be assessed through directed biopsy of metastatic sites, blood-based assays of circulating tumor cells, and cell-free nucleic acids, as reported by the Journal of Clinical Oncology 3
Tumor sequencing may reveal actionable mutations that can guide treatment decisions, as recommended by the National Comprehensive Cancer Network 5
Testing for mutations in genes such as BRCA1, BRCA2, ATM, CHEK2, or PALB2 may have implications for treatment and genetic counseling, as recommended by the National Comprehensive Cancer Network 5

CT scans, ultrasound, and MRI cannot always accurately predict the true depth of local invasion, as reported by the National Comprehensive Cancer Network 1
Conventional imaging has limited sensitivity for detecting small metastases, as reported by the European Urology 4
A single negative imaging study does not definitively rule out metastatic disease, especially with high clinical suspicion, although the source of this statement is not a preferred journal 2