How do you approach a patient with prostate cancer with sclerotic/lytic lesions found on a CT scan but not seen on a bone scan or PET-PSMA?

This can be a tough situation, as sometimes healthy individuals can have sclerotic or lytic foci in various bones for reasons unrelated to any type of malignancy. The first thing I would try to do is compare the CT scans to any prior imaging if possible. If these lesions are completely unchanged from years prior, it would be unlikely to represent metastatic disease.

If no prior CT comparisons are available, I would consider the overall clinicopathologic characteristics of the cancer. For instanc...

MRI may be helpful otherwise consider benign.

For this type of situation, one has to look at the overall clinical picture. What is the PSA and/or is it rising? If it's very low, I would be much less suspicious of these lesions and likely would follow with a repeat scan in a few months to assure stability then perhaps another in 6 months to a year to be sure they are unchanged. I would also likely get a PSA on him every 3 months or so for a year just to make sure there's no rapid increase/worry for progression.

As important, is his prior ima...