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Background  68Ga-PSMA PET/CT has an important role in assessment of prostate cancer patients with biochemical recurrence and is evolving in staging high- and intermediate risk disease. The aim of present study was to describe the metastatic patterns and frequency of involved sites of prostate cancer and to assess the incidence of benign Ga68-PSMA avid PET/CT findings in a large patient population.    Methods  68Ga-PSMA PET/CT studies performed in two tertiary medical centers over a period of 24 months were retrospectively reviewed. The incidence and location of pathological 68Ga-PSMA avid foci, suspicious to represent malignancy, as well as those of unexpected benign foci of increased 68Ga-PSMA activity were documented and analyzed.    Results  There were 445 68Ga-PSMA studies in 438 men (mean age 72.4, range 51–92 years) with prostate cancer referred for biochemical failure ( n  = 270, 61%), staging high-risk disease ( n  = 112, 25%), response assessment ( n  = 30, 7%), follow-up ( n  = 22, 5%) and suspected bone metastases (n = 11, 2%). 68Ga-PSMA avid disease sites were observed in 319 studies (72%), in 181 studies (67%) for biochemical recurrence, 94 studies for staging (84%) ( p  < 0.05), in 22 studies for response assessment (73%), 10 follow up studies (45%) and in five patients with suspected bone metastases (45%). 68Ga-PSMA avid lesions were most commonly detected in the prostate ( n  = 193, 43%), loco-regional spread ( n  = 51, 11%), abdomino-pelvic nodes ( n  = 129, 29%) and distant metastases ( n  = 158, 36%), including bone metastases ( n  = 11, 25%), distant lymphadenopathy ( n  = 29, 7%) and other organs ( n  = 18, 4%). Distant 68Ga-PSMA-avid metastases were commonly seen in patients with biochemical recurrence (14/21 lesions), but were not seen in patient referred for staging ( p  < 0.013). There were 96 non-malignant 68Ga-PSMA avid foci in 81 studies, most common in reactive lymph nodes ( n  = 36, 38%), nonmalignant bone lesions ( n  = 21, 22%), thyroid nodules ( n  = 9, 9%), ganglions (n = 9, 9%) and lung findings ( n  = 8, 8%).    Conclusion  The distribution of 68Ga-PSMA avid metastatic lesions is similar to data previously reported mainly from autopsy with comparable detection rates, indicating 68Ga-PSMA PET/CT is an accurate detection tool in patients with metastatic prostate cancer. If confirmed by further prospective studies 68Ga-PSMA PET/CT should be included in the guidelines to evaluate disease extent in these patients.

68Ga-PSMA PET/CT in prostate cancer patients – patterns of disease, benign findings and pitfalls