Redefining High-Risk Prostate Cancer Staging: The Role of PSMA-PET and the Promise Criteria

Abstract Staging is a pivotal step in the management of high-risk prostate cancer. Traditionally reliant on CT and bone scans, the diagnostic landscape has evolved dramatically with the advent of prostate-specific membrane antigen positron emission tomography (PSMA-PET). This imaging modality, with superior accuracy and reduced radiation burden, not only improves detection of nodal and distant disease but also alters therapeutic strategies in a substantial proportion of patients. In parallel, the development of the PROMISE (Prostate Cancer Molecular Imaging Standardized Evaluation) criteria has introduced a standardized framework for PSMA-PET interpretation, harmonizing staging across institutions and enhancing prognostic assessments. This review integrates current evidence, including recent randomized trials and prospective registries, and explores how PSMA-PET and PROMISE are reshaping the staging and clinical management of high-risk prostate cancer. Keywords: PSMA-PET, PROMISE criteria, prostate cancer, high-risk, miTNM, staging, imaging biomarkers