Prostate-specific membrane antigen (PSMA) PET/CT has transformed prostate cancer assessment and is now embedded in guideline-recommended care. Yet the usefulness of advanced imaging depends on how consistently results are communicated. An analysis of consecutive external PSMA PET/CT reports received at a single tertiary centre highlights substantial heterogeneity in length, readability and content, alongside limited uptake of structured scoring systems. The findings span reports from academic, community, private and Veterans Affairs providers, offering a broad window into contemporary reporting practices. Variability in lesion descriptions, incomplete longitudinal comparisons and frequent but loosely managed incidental findings suggest opportunities to improve clarity, align interpretation frameworks and support timely clinical decision-making.
Marked Variability in Report Content
Across 111 reports from 42 institutions, report origins were mixed: 58 from academic sites, 50 from community or private practices and three from Veterans Affairs hospitals. Length varied widely, with a mean of 369 words ± 139 and a range from 74 to 843 words. Readability was also inconsistent, the mean Flesch-Kincaid Grade Level was 15.03 ± 13.01, indicating text often written at a level considered very difficult to read.
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Use of formal interpretation frameworks was uncommon. Only 12 of 111 reports (11%) applied a standardised scoring system, with no difference in utilisation between academic and nonacademic practices (P = .28). Longitudinal assessment was uneven. Of 72 reports that referenced prior examinations, only 28 (39%) provided longitudinal assessment for all lesions mentioned, limiting clarity on interval change that can guide treatment planning.
Lesion-level reporting showed further heterogeneity. Among 90 reports describing prostate lesions, 83 (92%) documented standardised uptake value but far fewer recorded other key features. Four (4.4%) reported lesion size, three (3.3%) noted likelihood of extracapsular extension and 13 (14%) addressed seminal vesicle invasion. For nodal or distant metastases, which were identified in 41 of 111 reports (37%), documentation was similarly uneven: 35 (85%) reported standardised uptake value, 11 (27%) included size and four (10%) described CT features for all lesions mentioned. Such variation complicates comparisons within and across institutions, particularly for staging and restaging where different frameworks emphasise different criteria.
Incidental Findings Often Lack Guidance
Incidental findings were common and numerous. They were mentioned in 99 of 111 reports (89%), with a median of four per patient and an interquartile range of 0–17. The most frequently reported categories were coronary or vascular calcifications or atherosclerosis in 58 patients (52%), bone or joint abnormalities in 51 (46%) and pulmonary nodules in 36 (32%). While many incidental findings fall outside the genitourinary tract, they can still influence management by prompting referral, surveillance or additional diagnostic work.
Despite their prevalence, management recommendations were scarce. When incidental findings were documented, explicit guidance on next steps was provided in only 17 of 99 patients (17%). This leaves referring teams to interpret clinical relevance and follow-up needs, potentially increasing workload and the risk of missed or delayed actions. The downstream impact of such findings for providers and patients remains largely unknown, yet the frequency of incidental observations underscores the importance of concise, actionable communication within the report narrative.
Readability adds another layer of complexity. With an average grade level at or above college, reports may be difficult for patients to understand. This matters because a high proportion of results are viewed by patients via electronic portals before the ordering clinician reviews them. In that context, dense or highly technical language can create confusion, anxiety or misinterpretation and may complicate subsequent clinical conversations.
Toward Consistent Interpretation and Communication
Limited adoption of structured frameworks in PSMA PET/CT mirrors wider oncology imaging practice, where structured reporting is not universally used. Within PSMA PET/CT itself, the coexistence of multiple systems and criteria contributes to uneven implementation. PROMISE focuses on molecular imaging TNM classification with relative uptake thresholds, whereas PSMA-RADS aims to characterise individual lesions holistically. Differences in emphasis can yield divergent reporting content, making comparisons difficult across time, modalities and institutions.
A pathway to greater alignment is emerging. The Standardized PSMA PET Analysis and Reporting Consensus (SPARC) initiative brings together a multidisciplinary panel of 30 experts to develop a common lexicon, streamline research, prioritise key issues, reduce heterogeneity and unify previously parallel efforts. Until consolidated recommendations are available, multidisciplinary coordination within institutions remains essential to select and consistently apply validated frameworks to specific clinical questions. Options include PRIMARY for detecting clinically significant intraprostatic disease, miTNM/PROMISE for staging, PSMA expression scoring to inform radioligand therapy selection, PPP Criteria or RECIP for response assessment and PSMA-RADS for lesion characterisation.
Improving report structure and readability can complement framework adoption. Clear sections for clinical context, technique, findings and impression, consistent lesion descriptors and explicit longitudinal comparisons help referring clinicians navigate results quickly. When incidental findings are described, concise recommendations can support timely and appropriate follow-up. Aligning report language with diverse audiences, including patients who may access results before clinicians, can mitigate misunderstanding without diluting clinical precision.
PSMA PET/CT is central to prostate cancer care, yet current reports show wide variation in length, readability and content, with limited use of standardised scoring systems. Key lesion details and longitudinal assessments are inconsistently documented, and incidental findings frequently lack follow-up guidance. Consolidation efforts such as SPARC, combined with local multidisciplinary coordination and the deliberate application of validated frameworks to defined clinical questions, can reduce heterogeneity and strengthen communication. Clearer and more consistent reporting supports accurate interpretation, faster decisions and better coordination across teams managing prostate cancer.
Source: Radiology
Image Credit: iStock
